- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.20 / $96.78 / $105.59
| Professional | | $68.20 | $96.78 | $105.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.53 / $112.53 / $112.53
| Professional | | $112.53 | $112.53 | $112.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.33 / $51.33 / $51.33
| Professional | | $51.33 | $51.33 | $51.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.64 / $96.78 / $147.76
| Facility | | $86.64 | $96.78 | $147.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.57 / $61.26 / $130.11
| Professional | | $35.57 | $61.26 | $130.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.57 / $44.46 / $76.54
| Professional | | $35.57 | $44.46 | $76.54 |