- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.96 / $91.96 / $106.11
| Professional | | $91.96 | $91.96 | $106.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.78 / $107.78 / $107.78
| Facility | | $107.78 | $107.78 | $107.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.58 / $78.68 / $114.90
| Professional | | $59.58 | $78.68 | $114.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.78 / $107.78 / $107.78
| Facility | | $107.78 | $107.78 | $107.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.58 / $107.78 / $114.90
| Professional | | $59.58 | $107.78 | $114.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.28 / $85.28 / $107.57
| Facility | | $85.28 | $85.28 | $107.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.68 / $111.63 / $217.86
| Professional | | $62.68 | $111.63 | $217.86 |