- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.29 / $432.16 / $432.16
| Professional | | $77.29 | $432.16 | $432.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.45 / $131.06 / $198.61
| Facility | | $97.45 | $131.06 | $198.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.26 / $96.54 / $97.45
| Professional | | $37.26 | $96.54 | $97.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.45 / $114.26 / $198.61
| Facility | | $97.45 | $114.26 | $198.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.49 / $67.20 / $97.45
| Professional | | $60.49 | $67.20 | $97.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.23 / $28.23 / $92.40
| Professional | | $28.23 | $28.23 | $92.40 |