- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.08 / $109.41 / $545.46
| Professional | | $92.08 | $109.41 | $545.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.72 / $251.72 / $291.41
| Facility | | $251.72 | $251.72 | $291.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.70 / $108.62 / $211.94
| Professional | | $75.70 | $108.62 | $211.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.70 / $108.83 / $354.24
| Professional | | $75.70 | $108.83 | $354.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.14 / $105.14 / $105.14
| Facility | | $105.14 | $105.14 | $105.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.82 / $113.46 / $426.12
| Professional | | $95.82 | $113.46 | $426.12 |