- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.84 / $105.14 / $105.14
| Professional | | $69.84 | $105.14 | $105.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.58 / $103.58 / $103.58
| Facility | | $103.58 | $103.58 | $103.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.63 / $157.21 / $157.21
| Professional | | $133.63 | $157.21 | $157.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $63.35 / $95.32 / $114.44
| Facility | | $63.35 | $95.32 | $114.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.36 / $133.63 / $190.37
| Professional | | $119.36 | $133.63 | $190.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.59 / $178.77 / $194.75
| Professional | | $160.59 | $178.77 | $194.75 |