- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.32 / $117.59 / $179.34
| Professional | | $86.32 | $117.59 | $179.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.30 / $126.59 / $142.87
| Professional | | $48.30 | $126.59 | $142.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.46 / $142.87 / $204.02
| Facility | | $117.46 | $142.87 | $204.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.87 / $185.73 / $282.88
| Professional | | $142.87 | $185.73 | $282.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.65 / $60.58 / $111.81
| Professional | | $57.65 | $60.58 | $111.81 |