- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.47 / $91.64 / $114.55
| Professional | | $62.47 | $91.64 | $114.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.53 / $70.53 / $157.02
| Facility | | $70.53 | $70.53 | $157.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.49 / $70.53 / $189.38
| Professional | | $51.49 | $70.53 | $189.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.87 / $120.28 / $802.71
| Facility | | $118.87 | $120.28 | $802.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.57 / $93.70 / $130.15
| Professional | | $58.57 | $93.70 | $130.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.57 / $94.93 / $130.15
| Professional | | $58.57 | $94.93 | $130.15 |