- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.62 / $76.33 / $92.38
| Professional | | $51.62 | $76.33 | $92.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.62 / $106.62 / $106.62
| Facility | | $106.62 | $106.62 | $106.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.32 / $59.44 / $219.21
| Professional | | $38.32 | $59.44 | $219.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.45 / $89.53 / $153.19
| Professional | | $70.45 | $89.53 | $153.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.04 / $14.04 / $14.04
| Facility | | $14.04 | $14.04 | $14.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.49 / $50.86 / $79.68
| Professional | | $32.49 | $50.86 | $79.68 |