- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.34 / $88.58 / $137.93
| Professional | | $54.34 | $88.58 | $137.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.07 / $126.07 / $126.07
| Facility | | $126.07 | $126.07 | $126.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.07 / $126.07 / $126.07
| Professional | | $126.07 | $126.07 | $126.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $94.65 / $94.65 / $145.02
| Facility | | $94.65 | $94.65 | $145.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $80.45 / $94.65 / $124.23
| Professional | | $80.45 | $94.65 | $124.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.05 / $76.20 / $157.86
| Professional | | $47.05 | $76.20 | $157.86 |