- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.45 / $505.72 / $505.72
| Professional | | $90.45 | $505.72 | $505.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.04 / $153.37 / $232.41
| Facility | | $114.04 | $153.37 | $232.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.22 / $113.06 / $114.04
| Professional | | $27.22 | $113.06 | $114.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.50 / $133.71 / $232.41
| Facility | | $57.50 | $133.71 | $232.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.79 / $70.79 / $114.04
| Professional | | $70.79 | $70.79 | $114.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.64 / $33.03 / $78.65
| Professional | | $22.64 | $33.03 | $78.65 |