- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.69 / $114.69 / $132.33
| Professional | | $114.69 | $114.69 | $132.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.15 / $110.15 / $172.73
| Facility | | $110.15 | $110.15 | $172.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.41 / $110.14 / $117.42
| Professional | | $80.41 | $110.14 | $117.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.15 / $110.15 / $172.73
| Facility | | $110.15 | $110.15 | $172.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.41 / $110.14 / $117.42
| Professional | | $80.41 | $110.14 | $117.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.84 / $139.22 / $271.70
| Professional | | $79.84 | $139.22 | $271.70 |