- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.50 / $112.73 / $112.73
| Professional | | $105.50 | $112.73 | $112.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.63 / $165.63 / $165.63
| Facility | | $165.63 | $165.63 | $165.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.79 / $149.07 / $165.63
| Professional | | $140.79 | $149.07 | $165.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.50 / $70.81 / $103.96
| Facility | | $51.50 | $70.81 | $103.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.94 / $113.41 / $184.87
| Professional | | $58.94 | $113.41 | $184.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.28 / $161.78 / $181.08
| Professional | | $134.28 | $161.78 | $181.08 |