- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.65 / $81.59 / $96.72
| Professional | | $58.65 | $81.59 | $96.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.62 / $70.62 / $70.62
| Facility | | $70.62 | $70.62 | $70.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.06 / $88.03 / $171.25
| Professional | | $64.06 | $88.03 | $171.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.38 / $107.38 / $149.28
| Professional | | $107.38 | $107.38 | $149.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.22 / $102.36 / $214.20
| Professional | | $79.22 | $102.36 | $214.20 |