- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.72 / $98.42 / $127.35
| Professional | | $88.72 | $98.42 | $127.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.26 / $132.26 / $132.26
| Facility | | $132.26 | $132.26 | $132.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.26 / $132.26 / $132.26
| Professional | | $132.26 | $132.26 | $132.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.53 / $70.53 / $157.02
| Facility | | $70.53 | $70.53 | $157.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.49 / $70.53 / $128.61
| Professional | | $51.49 | $70.53 | $128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.98 / $81.11 / $141.86
| Professional | | $53.98 | $81.11 | $141.86 |