- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $70.73 / $76.31
| Professional | | $56.23 | $70.73 | $76.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.94 / $245.70 / $290.88
| Facility | | $181.94 | $245.70 | $290.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.49 / $67.63 / $113.09
| Professional | | $57.49 | $67.63 | $113.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.66 / $104.66 / $104.66
| Facility | | $104.66 | $104.66 | $104.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.96 / $104.66 / $104.66
| Professional | | $88.96 | $104.66 | $104.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.03 / $78.34 / $106.99
| Professional | | $58.03 | $78.34 | $106.99 |