- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.53 / $66.53 / $76.77
| Professional | | $66.53 | $66.53 | $76.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.20 / $104.21 / $104.21
| Facility | | $100.20 | $104.21 | $104.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.06 / $76.06 / $79.28
| Professional | | $76.06 | $76.06 | $79.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.20 / $104.21 / $104.21
| Facility | | $100.20 | $104.21 | $104.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.06 / $76.06 / $79.28
| Professional | | $76.06 | $76.06 | $79.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.66 / $102.46 / $113.39
| Professional | | $57.66 | $102.46 | $113.39 |