- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.53 / $93.52 / $119.91
| Professional | | $83.53 | $93.52 | $119.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.11 / $136.11 / $136.11
| Facility | | $136.11 | $136.11 | $136.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.11 / $136.11 / $136.11
| Professional | | $136.11 | $136.11 | $136.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.30 / $100.30 / $150.50
| Facility | | $100.30 | $100.30 | $150.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.26 / $100.30 / $114.85
| Professional | | $85.26 | $100.30 | $114.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.43 / $83.92 / $173.82
| Professional | | $50.43 | $83.92 | $173.82 |