- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.10 / $198.48 / $198.48
| Professional | | $27.10 | $198.48 | $198.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $39.35 / $74.83 / $74.83
| Facility | | $39.35 | $74.83 | $74.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.35 / $74.83 / $74.83
| Professional | | $39.35 | $74.83 | $74.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.11 / $71.27 / $74.83
| Facility | | $35.11 | $71.27 | $74.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.35 / $56.17 / $74.89
| Professional | | $39.35 | $56.17 | $74.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.40 / $31.42 / $48.08
| Professional | | $28.40 | $31.42 | $48.08 |