- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.22 / $49.33 / $53.23
| Professional | | $39.22 | $49.33 | $53.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.89 / $171.40 / $202.91
| Facility | | $126.89 | $171.40 | $202.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.83 / $58.62 / $78.89
| Professional | | $49.83 | $58.62 | $78.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.32 / $51.32 / $51.32
| Facility | | $51.32 | $51.32 | $51.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.46 / $51.32 / $51.32
| Professional | | $37.46 | $51.32 | $51.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.50 / $44.78 / $74.63
| Professional | | $32.50 | $44.78 | $74.63 |