- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.29 / $16.29 / $307.52
| Professional | | $16.29 | $16.29 | $307.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.59 / $257.56 / $429.19
| Facility | | $65.59 | $257.56 | $429.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.94 / $65.59 / $76.26
| Professional | | $54.94 | $65.59 | $76.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.33 / $281.33 / $281.33
| Professional | | $281.33 | $281.33 | $281.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16.29 / $307.52 / $439.75
| Facility | | $16.29 | $307.52 | $439.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.14 / $244.14 / $244.14
| Professional | | $244.14 | $244.14 | $244.14 |