- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.69 / $51.52 / $71.20
| Professional | | $39.69 | $51.52 | $71.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.21 / $211.21 / $211.21
| Facility | | $211.21 | $211.21 | $211.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.01 / $107.53 / $107.53
| Professional | | $105.01 | $107.53 | $107.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.71 / $38.71 / $38.71
| Professional | | $38.71 | $38.71 | $38.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.23 / $73.23 / $73.23
| Professional | | $73.23 | $73.23 | $73.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.69 / $51.52 / $71.20
| Professional | | $39.69 | $51.52 | $71.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.08 / $42.63 / $103.02
| Professional | | $35.08 | $42.63 | $103.02 |