- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.70 / $151.26 / $189.08
| Professional | | $123.70 | $151.26 | $189.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.18 / $52.44 / $71.26
| Facility | | $39.18 | $52.44 | $71.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.41 / $272.41 / $272.41
| Professional | | $272.41 | $272.41 | $272.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.00 / $67.00 / $67.00
| Facility | | $67.00 | $67.00 | $67.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.00 / $62.00 / $135.26
| Professional | | $47.00 | $62.00 | $135.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.91 / $68.18 / $107.64
| Professional | | $30.91 | $68.18 | $107.64 |