- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.26 / $76.37 / $77.34
| Professional | | $56.26 | $76.37 | $77.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.05 / $245.88 / $291.08
| Facility | | $182.05 | $245.88 | $291.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.10 / $84.10 / $116.44
| Professional | | $84.10 | $84.10 | $116.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.48 / $80.45 / $80.45
| Facility | | $74.48 | $80.45 | $80.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.73 / $80.45 / $80.45
| Professional | | $58.73 | $80.45 | $80.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.44 / $68.81 / $107.06
| Professional | | $54.44 | $68.81 | $107.06 |