- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.57 / $61.57 / $96.27
| Professional | | $61.57 | $61.57 | $96.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.37 / $107.37 / $107.37
| Facility | | $107.37 | $107.37 | $107.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.37 / $107.37 / $107.37
| Professional | | $107.37 | $107.37 | $107.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.52 / $64.52 / $136.28
| Facility | | $64.52 | $64.52 | $136.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.10 / $47.10 / $64.52
| Professional | | $47.10 | $47.10 | $64.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.56 / $51.52 / $57.19
| Professional | | $46.56 | $51.52 | $57.19 |