- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.11 / $49.63 / $500.13
| Professional | | $45.11 | $49.63 | $500.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.78 / $151.66 / $229.84
| Facility | | $112.78 | $151.66 | $229.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.86 / $111.51 / $112.78
| Professional | | $25.86 | $111.51 | $112.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $112.78 / $151.66 / $229.84
| Facility | | $112.78 | $151.66 | $229.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.00 / $70.00 / $112.78
| Professional | | $70.00 | $70.00 | $112.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.58 / $32.67 / $77.78
| Professional | | $21.58 | $32.67 | $77.78 |