- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.82 / $30.23 / $45.08
| Professional | | $25.82 | $30.23 | $45.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.94 / $549.28 / $682.08
| Facility | | $141.94 | $549.28 | $682.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.48 / $37.03 / $37.03
| Professional | | $31.48 | $37.03 | $37.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.11 / $145.11 / $145.11
| Facility | | $145.11 | $145.11 | $145.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.31 / $39.14 / $167.21
| Professional | | $15.31 | $39.14 | $167.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.58 / $32.54 / $51.46
| Professional | | $23.58 | $32.54 | $51.46 |