- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.05 / $85.33 / $114.91
| Professional | | $73.05 | $85.33 | $114.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.18 / $157.47 / $177.16
| Facility | | $113.18 | $157.47 | $177.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.81 / $144.35 / $304.25
| Professional | | $121.81 | $144.35 | $304.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.14 / $124.14 / $124.14
| Facility | | $124.14 | $124.14 | $124.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.24 / $47.24 / $47.24
| Professional | | $47.24 | $47.24 | $47.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.20 / $65.47 / $109.61
| Professional | | $48.20 | $65.47 | $109.61 |