- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.25 / $125.29 / $130.56
| Professional | | $95.25 | $125.29 | $130.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.52 / $98.26 / $154.94
| Professional | | $83.52 | $98.26 | $154.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.88 / $105.88 / $105.88
| Facility | | $105.88 | $105.88 | $105.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.08 / $78.08 / $78.08
| Professional | | $78.08 | $78.08 | $78.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.33 / $117.06 / $117.06
| Professional | | $116.33 | $117.06 | $117.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.25 / $125.29 / $131.44
| Professional | | $95.25 | $125.29 | $131.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.33 / $135.36 / $195.17
| Professional | | $100.33 | $135.36 | $195.17 |