- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.87 / $370.67 / $370.67
| Professional | | $106.87 | $370.67 | $370.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.21 / $110.24 / $110.24
| Facility | | $60.21 | $110.24 | $110.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.21 / $89.64 / $110.24
| Professional | | $60.21 | $89.64 | $110.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.72 / $104.99 / $110.24
| Facility | | $53.72 | $104.99 | $110.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.21 / $82.74 / $112.91
| Professional | | $60.21 | $82.74 | $112.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.45 / $48.07 / $76.23
| Professional | | $43.45 | $48.07 | $76.23 |