- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.56 / $73.20 / $96.51
| Professional | | $66.56 | $73.20 | $96.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.80 / $204.80 / $235.20
| Facility | | $204.80 | $204.80 | $235.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.36 / $70.36 / $70.36
| Professional | | $70.36 | $70.36 | $70.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.36 / $70.36 / $70.36
| Professional | | $70.36 | $70.36 | $70.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.52 / $66.25 / $76.58
| Professional | | $60.52 | $66.25 | $76.58 |