- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $57.54 / $162.18
| Professional | | $44.67 | $57.54 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $208.93 / $245.47
| Facility | | $151.36 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $58.88 / $112.20
| Professional | | $44.67 | $58.88 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.26 / $60.26 / $60.26
| Facility | | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.65 / $43.65 / $60.26
| Professional | | $43.65 | $43.65 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $47.86 / $58.88 / $131.83
| Facility | | $47.86 | $58.88 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.67 / $56.23 / $87.10
| Professional | | $44.67 | $56.23 | $87.10 |