- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.64 / $83.47 / $83.47
| Professional | | $61.64 | $83.47 | $83.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.10 / $40.10 / $44.11
| Facility | | $40.10 | $40.10 | $44.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.94 / $111.94 / $133.66
| Professional | | $111.94 | $111.94 | $133.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.20 / $385.20 / $385.20
| Professional | | $385.20 | $385.20 | $385.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.64 / $83.47 / $91.82
| Facility | | $61.64 | $83.47 | $91.82 |