- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.22 / $64.22 / $112.46
| Professional | | $64.22 | $64.22 | $112.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.42 / $125.42 / $125.42
| Facility | | $125.42 | $125.42 | $125.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.42 / $125.42 / $125.42
| Professional | | $125.42 | $125.42 | $125.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.70 / $100.70 / $138.82
| Facility | | $100.70 | $100.70 | $138.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.60 / $85.60 / $112.51
| Professional | | $85.60 | $85.60 | $112.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.10 / $56.53 / $87.11
| Professional | | $51.10 | $56.53 | $87.11 |