- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.91 / $87.47 / $116.83
| Professional | | $81.91 | $87.47 | $116.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $271.77 / $394.98
| Facility | | $246.23 | $271.77 | $394.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.53 / $119.45 / $144.57
| Professional | | $101.53 | $119.45 | $144.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.50 / $123.50 / $123.50
| Facility | | $123.50 | $123.50 | $123.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.98 / $123.50 / $123.50
| Professional | | $104.98 | $123.50 | $123.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.40 / $111.41 / $162.01
| Professional | | $79.40 | $111.41 | $162.01 |