- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.31 / $75.63 / $75.63
| Professional | | $73.31 | $75.63 | $75.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.63 / $105.67 / $132.87
| Professional | | $104.63 | $105.67 | $132.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.31 / $73.31 / $90.29
| Facility | | $73.31 | $73.31 | $90.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.29 / $37.54 / $487.04
| Professional | | $31.29 | $37.54 | $487.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.40 / $31.29 / $70.26
| Professional | | $29.40 | $31.29 | $70.26 |