- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.81 / $80.65 / $104.52
| Professional | | $72.81 | $80.65 | $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
- $57.76 / $57.76 / $131.21
| Facility | | $57.76 | $57.76 | $131.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.10 / $57.76 / $103.09
| Professional | | $49.10 | $57.76 | $103.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.38 / $62.07 / $109.29
| Professional | | $44.38 | $62.07 | $109.29 |