- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.14 / $44.05 / $175.14
| Professional | | $32.14 | $44.05 | $175.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $24.81 / $32.40 / $70.34
| Facility | | $24.81 | $32.40 | $70.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.40 / $32.40 / $32.40
| Professional | | $32.40 | $32.40 | $32.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.70 / $34.70 / $34.70
| Professional | | $34.70 | $34.70 | $34.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $145.74 / $436.03 / $436.03
| Facility | | $145.74 | $436.03 | $436.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $455.63 / $698.25 / $698.25
| Professional | | $455.63 | $698.25 | $698.25 |