- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.22 / $49.33 / $53.23
| Professional | | $39.22 | $49.33 | $53.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.89 / $171.40 / $202.91
| Facility | | $126.89 | $171.40 | $202.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.62 / $76.29 / $78.89
| Professional | | $72.62 | $76.29 | $78.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.03 / $57.03 / $57.03
| Facility | | $57.03 | $57.03 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.63 / $57.03 / $57.03
| Professional | | $41.63 | $57.03 | $57.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.06 / $44.78 / $74.63
| Professional | | $35.06 | $44.78 | $74.63 |