- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.51 / $97.51 / $112.52
| Professional | | $97.51 | $97.51 | $112.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.87 / $172.35 / $172.35
| Facility | | $146.87 | $172.35 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.44 / $135.46 / $177.52
| Professional | | $124.44 | $135.46 | $177.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.87 / $172.35 / $172.35
| Facility | | $146.87 | $172.35 | $172.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.44 / $172.35 / $177.52
| Professional | | $124.44 | $172.35 | $177.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.74 / $131.74 / $157.84
| Facility | | $131.74 | $131.74 | $157.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.12 / $118.37 / $231.01
| Professional | | $69.12 | $118.37 | $231.01 |