- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $75.86 / $104.71
| Professional | | $57.54 | $75.86 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $91.20 / $91.20 / $128.82
| Facility | | $91.20 | $91.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $67.61 / $114.82
| Professional | | $67.61 | $67.61 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.65 / $56.23 / $114.82
| Facility | | $43.65 | $56.23 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.29 / $57.54 / $87.10
| Professional | | $51.29 | $57.54 | $87.10 |