- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.70 / $143.75 / $154.16
| Professional | | $72.70 | $143.75 | $154.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.51 / $84.51 / $84.51
| Professional | | $84.51 | $84.51 | $84.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.55 / $148.88 / $176.06
| Facility | | $111.55 | $148.88 | $176.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.72 / $176.06 / $184.86
| Professional | | $134.72 | $176.06 | $184.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $308.11 / $343.32
| Professional | | $30.00 | $308.11 | $343.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.20 / $83.59 / $87.83
| Professional | | $81.20 | $83.59 | $87.83 |