- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.26 / $63.81 / $106.81
| Professional | | $53.26 | $63.81 | $106.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $29.00 / $44.00
| Professional | | $15.00 | $29.00 | $44.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.00 / $49.50 / $84.60
| Professional | | $36.00 | $49.50 | $84.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $1,974.91 / $1,974.91
| Facility | | $85.00 | $1,974.91 | $1,974.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.00 / $177.81 / $177.81
| Professional | | $177.00 | $177.81 | $177.81 |