- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.76 / $77.47 / $77.47
| Professional | | $55.76 | $77.47 | $77.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.52 / $147.08 / $272.64
| Facility | | $113.52 | $147.08 | $272.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.96 / $61.09 / $61.09
| Professional | | $57.96 | $61.09 | $61.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.81 / $62.81 / $93.81
| Facility | | $62.81 | $62.81 | $93.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.85 / $45.85 / $62.81
| Professional | | $45.85 | $45.85 | $62.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.34 / $103.34 / $103.34
| Professional | | $103.34 | $103.34 | $103.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.49 / $71.87 / $77.47
| Professional | | $57.49 | $71.87 | $77.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.45 / $63.68 / $146.44
| Professional | | $42.45 | $63.68 | $146.44 |