- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.84 / $85.53 / $112.43
| Professional | | $75.84 | $85.53 | $112.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.84 / $102.96 / $112.17
| Facility | | $93.84 | $102.96 | $112.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.18 / $94.38 / $99.71
| Professional | | $51.18 | $94.38 | $99.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.28 / $100.28 / $100.28
| Facility | | $100.28 | $100.28 | $100.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.04 / $104.50 / $190.27
| Professional | | $74.04 | $104.50 | $190.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.83 / $99.24 / $141.83
| Professional | | $65.83 | $99.24 | $141.83 |