- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.68 / $132.81 / $152.10
| Professional | | $121.68 | $132.81 | $152.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.70 / $147.29 / $335.79
| Professional | | $100.70 | $147.29 | $335.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.38 / $109.74 / $139.85
| Facility | | $87.38 | $109.74 | $139.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.61 / $109.74 / $147.29
| Professional | | $75.61 | $109.74 | $147.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.90 / $122.50 / $173.30
| Professional | | $56.90 | $122.50 | $173.30 |