- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.59 / $57.92 / $82.13
| Professional | | $42.59 | $57.92 | $82.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.43 / $105.16 / $105.16
| Facility | | $100.43 | $105.16 | $105.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.53 / $100.43 / $105.16
| Professional | | $75.53 | $100.43 | $105.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.54 / $64.00 / $105.16
| Facility | | $50.54 | $64.00 | $105.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.79 / $97.06 / $153.28
| Professional | | $61.79 | $97.06 | $153.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.59 / $114.56 / $137.86
| Professional | | $93.59 | $114.56 | $137.86 |