- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.83 / $76.83 / $92.20
| Professional | | $76.83 | $76.83 | $92.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.75 / $85.60 / $107.63
| Professional | | $84.75 | $85.60 | $107.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.68 / $92.57 / $133.81
| Facility | | $78.68 | $92.57 | $133.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.57 / $92.57 / $103.68
| Professional | | $92.57 | $92.57 | $103.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.57 / $92.57 / $95.62
| Professional | | $92.57 | $92.57 | $95.62 |