- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.67 / $72.23 / $95.22
| Professional | | $65.67 | $72.23 | $95.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.16 / $165.16 / $165.16
| Facility | | $165.16 | $165.16 | $165.16 |
- 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
- $165.16 / $165.16 / $165.16
| Facility | | $165.16 | $165.16 | $165.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.25 / $72.25 / $72.25
| Professional | | $72.25 | $72.25 | $72.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.73 / $77.26 / $118.85
| Professional | | $69.73 | $77.26 | $118.85 |