- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.08 / $222.22 / $222.22
| Professional | | $64.08 | $222.22 | $222.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.53 / $57.53 / $57.53
| Professional | | $57.53 | $57.53 | $57.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.36 / $61.86 / $61.86
| Facility | | $37.36 | $61.86 | $61.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.36 / $50.30 / $61.86
| Professional | | $37.36 | $50.30 | $61.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $32.21 / $58.91 / $61.86
| Facility | | $32.21 | $58.91 | $61.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.36 / $46.42 / $67.45
| Professional | | $37.36 | $46.42 | $67.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.05 / $28.82 / $44.41
| Professional | | $26.05 | $28.82 | $44.41 |