- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.81 / $81.73 / $104.52
| Professional | | $72.81 | $81.73 | $104.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.24 / $104.24 / $104.24
| Facility | | $104.24 | $104.24 | $104.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.24 / $104.24 / $104.24
| Professional | | $104.24 | $104.24 | $104.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.42 / $96.42 / $131.21
| Facility | | $96.42 | $96.42 | $131.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.96 / $96.42 / $106.80
| Professional | | $81.96 | $96.42 | $106.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.38 / $62.07 / $112.77
| Professional | | $44.38 | $62.07 | $112.77 |