- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.22 / $73.41 / $92.19
| Professional | | $64.22 | $73.41 | $92.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $102.55 / $102.55 / $102.55
| Facility | | $102.55 | $102.55 | $102.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.55 / $102.55 / $102.55
| Professional | | $102.55 | $102.55 | $102.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.67 / $74.67 / $115.70
| Facility | | $74.67 | $74.67 | $115.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.47 / $74.67 / $88.56
| Professional | | $63.47 | $74.67 | $88.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.78 / $58.73 / $114.36
| Professional | | $37.78 | $58.73 | $114.36 |