- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.56 / $91.23 / $115.82
| Professional | | $72.56 | $91.23 | $115.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.31 / $138.31 / $138.31
| Facility | | $138.31 | $138.31 | $138.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.65 / $121.30 / $135.94
| Professional | | $91.65 | $121.30 | $135.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.49 / $135.56 / $191.54
| Professional | | $83.49 | $135.56 | $191.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.05 / $111.99 / $208.30
| Professional | | $81.05 | $111.99 | $208.30 |