- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.93 / $68.06 / $120.12
| Professional | | $45.93 | $68.06 | $120.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $337.87 / $337.87 / $432.69
| Facility | | $337.87 | $337.87 | $432.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.85 / $86.37 / $225.31
| Professional | | $47.85 | $86.37 | $225.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.19 / $103.16 / $225.31
| Professional | | $64.19 | $103.16 | $225.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.63 / $99.42 / $300.89
| Professional | | $77.63 | $99.42 | $300.89 |