- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.00 / $56.75 / $594.66
| Professional | | $40.00 | $56.75 | $594.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.26 / $102.26 / $128.59
| Professional | | $102.26 | $102.26 | $128.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.91 / $123.23 / $136.63
| Professional | | $102.91 | $123.23 | $136.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $283.58 / $283.58 / $283.58
| Facility | | $283.58 | $283.58 | $283.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.90 / $49.29 / $59.45
| Professional | | $41.90 | $49.29 | $59.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.56 / $47.53 / $70.81
| Professional | | $29.56 | $47.53 | $70.81 |