- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $79.43 / $91.20
| Professional | | $57.54 | $79.43 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $309.03 / $426.58
| Facility | | $257.04 | $309.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.54 / $30.90 / $36.31
| Professional | | $27.54 | $30.90 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $67.61 / $107.15
| Professional | | $67.61 | $67.61 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $93.33 / $144.54
| Professional | | $93.33 | $93.33 | $144.54 |