- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.23 / $73.80 / $95.07
| Professional | | $66.23 | $73.80 | $95.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.78 / $104.78 / $104.78
| Facility | | $104.78 | $104.78 | $104.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.78 / $104.78 / $104.78
| Professional | | $104.78 | $104.78 | $104.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.15 / $78.15 / $119.33
| Facility | | $78.15 | $78.15 | $119.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.43 / $78.15 / $92.68
| Professional | | $66.43 | $78.15 | $92.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.72 / $60.56 / $113.80
| Professional | | $38.72 | $60.56 | $113.80 |