- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.22 / $82.28 / $82.28
| Professional | | $59.22 | $82.28 | $82.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.57 / $156.21 / $289.56
| Facility | | $120.57 | $156.21 | $289.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.80 / $86.28 / $86.28
| Professional | | $82.80 | $86.28 | $86.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.04 / $112.36 / $112.36
| Facility | | $95.04 | $112.36 | $112.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.02 / $82.02 / $112.36
| Professional | | $82.02 | $82.02 | $112.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.75 / $109.75 / $109.75
| Professional | | $109.75 | $109.75 | $109.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.33 / $82.28 / $82.28
| Professional | | $76.33 | $82.28 | $82.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.08 / $72.75 / $155.51
| Professional | | $45.08 | $72.75 | $155.51 |