- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.68 / $49.58 / $67.61
| Professional | | $37.68 | $49.58 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.24 / $203.24 / $203.24
| Facility | | $203.24 | $203.24 | $203.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.91 / $103.33 / $103.33
| Professional | | $100.91 | $103.33 | $103.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.20 / $37.20 / $37.20
| Professional | | $37.20 | $37.20 | $37.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.45 / $70.45 / $70.45
| Professional | | $70.45 | $70.45 | $70.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.68 / $49.58 / $67.61
| Professional | | $37.68 | $49.58 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.74 / $42.73 / $99.14
| Professional | | $28.74 | $42.73 | $99.14 |