- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.42 / $320.56 / $320.56
| Professional | | $92.42 | $320.56 | $320.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.38 / $120.84 / $120.84
| Facility | | $90.38 | $120.84 | $120.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.38 / $120.84 / $120.84
| Professional | | $90.38 | $120.84 | $120.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.70 / $115.09 / $120.84
| Facility | | $56.70 | $115.09 | $120.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.38 / $90.69 / $120.92
| Professional | | $90.38 | $90.69 | $120.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.86 / $50.74 / $78.18
| Professional | | $45.86 | $50.74 | $78.18 |