- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.44 / $87.10 / $104.71
| Professional | | $72.44 | $87.10 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.54 / $57.54 / $102.33
| Facility | | $57.54 | $57.54 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.98 / $57.54 / $102.33
| Professional | | $48.98 | $57.54 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6.31 / $45.71 / $83.18
| Facility | | $6.31 | $45.71 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $61.66 / $112.20
| Professional | | $44.67 | $61.66 | $112.20 |