- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.67 / $65.67 / $72.23
| Professional | | $65.67 | $65.67 | $72.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.25 / $72.25 / $72.25
| Facility | | $72.25 | $72.25 | $72.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.25 / $72.25 / $72.25
| Professional | | $72.25 | $72.25 | $72.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.67 / $69.61 / $93.91
| Facility | | $65.67 | $69.61 | $93.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.72 / $110.36 / $160.56
| Facility | | $104.72 | $110.36 | $160.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.26 / $88.08 / $88.08
| Professional | | $77.26 | $88.08 | $88.08 |