- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.81 / $84.86 / $87.97
| Professional | | $64.81 | $84.86 | $87.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.71 / $283.25 / $335.33
| Facility | | $209.71 | $283.25 | $335.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.35 / $96.88 / $134.13
| Professional | | $82.35 | $96.88 | $134.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.80 / $102.60 / $102.60
| Facility | | $85.80 | $102.60 | $102.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.90 / $102.60 / $102.60
| Professional | | $74.90 | $102.60 | $102.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.74 / $79.29 / $123.33
| Professional | | $59.74 | $79.29 | $123.33 |