- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.10 / $64.48 / $103.45
| Professional | | $30.10 | $64.48 | $103.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.36 / $106.74 / $138.57
| Facility | | $73.36 | $106.74 | $138.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.16 / $106.74 / $172.84
| Professional | | $106.16 | $106.74 | $172.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.34 / $98.44 / $138.57
| Facility | | $70.34 | $98.44 | $138.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $82.50 / $117.13
| Professional | | $55.00 | $82.50 | $117.13 |