- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.70 / $73.70 / $103.50
| Facility | | $73.70 | $73.70 | $103.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.93 / $100.86 / $107.43
| Professional | | $60.93 | $100.86 | $107.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.40 / $83.40 / $83.40
| Professional | | $83.40 | $83.40 | $83.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.08 / $73.70 / $112.92
| Facility | | $41.08 | $73.70 | $112.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.38 / $217.50 / $659.14
| Professional | | $141.38 | $217.50 | $659.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.16 / $200.16 / $220.78
| Professional | | $111.16 | $200.16 | $220.78 |