- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.33 / $71.33 / $119.66
| Professional | | $71.33 | $71.33 | $119.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.87 / $141.87 / $236.45
| Facility | | $141.87 | $141.87 | $236.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.60 / $47.60 / $47.60
| Professional | | $47.60 | $47.60 | $47.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.87 / $141.87 / $236.45
| Facility | | $141.87 | $141.87 | $236.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.60 / $47.60 / $47.60
| Professional | | $47.60 | $47.60 | $47.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.34 / $46.67 / $71.79
| Professional | | $44.34 | $46.67 | $71.79 |