- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.38 / $81.38 / $101.72
| Professional | | $81.38 | $81.38 | $101.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.08 / $165.08 / $165.08
| Facility | | $165.08 | $165.08 | $165.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $158.66 / $158.66
| Professional | | $105.39 | $158.66 | $158.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.10 / $105.39 / $105.39
| Facility | | $94.10 | $105.39 | $105.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.79 / $105.39 / $158.66
| Professional | | $76.79 | $105.39 | $158.66 |