- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.59 / $104.75 / $156.66
| Professional | | $78.59 | $104.75 | $156.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $98.21 / $98.21 / $115.43
| Facility | | $98.21 | $98.21 | $115.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.60 / $102.60 / $102.60
| Professional | | $102.60 | $102.60 | $102.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.78 / $149.78 / $149.78
| Facility | | $149.78 | $149.78 | $149.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.25 / $120.77 / $207.87
| Professional | | $87.25 | $120.77 | $207.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.81 / $111.38 / $206.15
| Professional | | $89.81 | $111.38 | $206.15 |