- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.16 / $526.49 / $526.49
| Professional | | $94.16 | $526.49 | $526.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.73 / $159.66 / $241.96
| Facility | | $118.73 | $159.66 | $241.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.63 / $117.71 / $118.73
| Professional | | $47.63 | $117.71 | $118.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.73 / $159.66 / $241.96
| Facility | | $118.73 | $159.66 | $241.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.69 / $73.69 / $118.73
| Professional | | $73.69 | $73.69 | $118.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.39 / $34.39 / $95.13
| Professional | | $34.39 | $34.39 | $95.13 |