- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $104.71 / $158.49
| Professional | | $93.33 | $104.71 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $218.78
| Facility | | $112.20 | $112.20 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $81.28 / $177.83
| Professional | | $81.28 | $81.28 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $67.61 / $89.13 / $144.54
| Facility | | $67.61 | $89.13 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.28 / $89.13 / $134.90
| Professional | | $81.28 | $89.13 | $134.90 |