- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.06 / $100.55 / $137.03
| Professional | | $51.06 | $100.55 | $137.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.64 / $300.64 / $300.64
| Facility | | $300.64 | $300.64 | $300.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.60 / $111.92 / $176.65
| Professional | | $58.60 | $111.92 | $176.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.48 / $132.97 / $176.65
| Professional | | $71.48 | $132.97 | $176.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.59 / $159.43 / $285.18
| Professional | | $94.59 | $159.43 | $285.18 |