- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.89 / $96.14 / $150.33
| Professional | | $86.89 | $96.14 | $150.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $167.66 / $167.66 / $167.66
| Facility | | $167.66 | $167.66 | $167.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.66 / $167.66 / $167.66
| Professional | | $167.66 | $167.66 | $167.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.45 / $80.45 / $141.63
| Facility | | $80.45 | $80.45 | $141.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.73 / $58.73 / $80.45
| Professional | | $58.73 | $58.73 | $80.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.06 / $64.23 / $71.31
| Professional | | $58.06 | $64.23 | $71.31 |