- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.42 / $28.18 / $72.44
| Professional | | $20.42 | $28.18 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $204.17 / $302.00
| Facility | | $141.25 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $26.30 / $39.81
| Professional | | $19.50 | $26.30 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Facility | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.55 / $24.55 / $35.48
| Professional | | $24.55 | $24.55 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.12 / $33.11 / $53.70
| Professional | | $25.12 | $33.11 | $53.70 |