- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.46 / $74.04 / $75.51
| Professional | | $59.46 | $74.04 | $75.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $81.13 / $136.44 / $279.63
| Facility | | $81.13 | $136.44 | $279.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.27 / $117.84 / $350.74
| Professional | | $81.27 | $117.84 | $350.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $101.00 / $101.00 / $101.00
| Facility | | $101.00 | $101.00 | $101.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.27 / $101.00 / $150.86
| Professional | | $81.27 | $101.00 | $150.86 |