- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $64.57 / $204.17
| Professional | | $61.66 | $64.57 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $263.03 / $309.03
| Facility | | $194.98 | $263.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $74.13 / $141.25
| Professional | | $56.23 | $74.13 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.13 / $77.62 / $77.62
| Facility | | $74.13 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.70 / $53.70 / $74.13
| Professional | | $53.70 | $53.70 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $72.44 / $158.49
| Facility | | $57.54 | $72.44 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.88 / $72.44 / $109.65
| Professional | | $58.88 | $72.44 | $109.65 |