- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.86 / $357.76 / $357.76
| Professional | | $48.86 | $357.76 | $357.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.72 / $106.83 / $106.83
| Facility | | $66.72 | $106.83 | $106.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.72 / $86.87 / $106.83
| Professional | | $66.72 | $86.87 | $106.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.72 / $101.74 / $106.83
| Facility | | $56.72 | $101.74 | $106.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.72 / $80.17 / $117.00
| Professional | | $66.72 | $80.17 | $117.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.88 / $50.75 / $77.67
| Professional | | $45.88 | $50.75 | $77.67 |