- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.15 / $252.44 / $252.44
| Professional | | $45.15 | $252.44 | $252.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.93 / $66.73 / $223.78
| Facility | | $56.93 | $66.73 | $223.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.16 / $56.93 / $56.93
| Professional | | $24.16 | $56.93 | $56.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.93 / $66.73 / $223.78
| Facility | | $56.93 | $66.73 | $223.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.33 / $35.33 / $56.93
| Professional | | $35.33 | $35.33 | $56.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.48 / $16.48 / $39.26
| Professional | | $16.48 | $16.48 | $39.26 |