- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $72.44
| Professional | | $57.54 | $57.54 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.15 / $57.54 / $1,778.28
| Facility | | $37.15 | $57.54 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $162.18 / $162.18
| Professional | | $39.81 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |