- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.02 / $76.70 / $128.38
| Professional | | $64.02 | $76.70 | $128.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.25 / $70.58 / $134.66
| Facility | | $53.25 | $70.58 | $134.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.80 / $64.40 / $114.40
| Professional | | $46.80 | $64.40 | $114.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.30 / $243.60 / $243.60
| Facility | | $91.30 | $243.60 | $243.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $240.00 / $240.00
| Professional | | $240.00 | $240.00 | $240.00 |