- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.30 / $133.72 / $302.20
| Professional | | $83.30 | $133.72 | $302.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.73 / $100.73 / $128.99
| Facility | | $100.73 | $100.73 | $128.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.67 / $78.67 / $78.67
| Facility | | $78.67 | $78.67 | $78.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.41 / $105.41 / $105.41
| Professional | | $105.41 | $105.41 | $105.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.67 / $78.67 / $78.67
| Facility | | $78.67 | $78.67 | $78.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.55 / $30.55 / $105.41
| Professional | | $30.55 | $30.55 | $105.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.53 / $47.00 / $108.59
| Professional | | $20.53 | $47.00 | $108.59 |