- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.50 / $174.51 / $180.60
| Professional | | $115.50 | $174.51 | $180.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.92 / $202.92 / $202.92
| Professional | | $202.92 | $202.92 | $202.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.60 / $104.60 / $104.60
| Professional | | $104.60 | $104.60 | $104.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.22 / $174.51 / $266.43
| Facility | | $156.22 | $174.51 | $266.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $110.46 / $234.59
| Professional | | $72.48 | $110.46 | $234.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.48 / $104.48 / $155.97
| Professional | | $72.48 | $104.48 | $155.97 |