- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $91.20
| Professional | | $72.44 | $72.44 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $70.79 / $269.15
| Facility | | $47.86 | $70.79 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $173.78 / $173.78
| Professional | | $43.65 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $72.44 / $72.44
| Professional | | $72.44 | $72.44 | $72.44 |