- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.75 / $46.75 / $240.85
| Professional | | $46.75 | $46.75 | $240.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.74 / $246.32 / $410.45
| Facility | | $62.74 | $246.32 | $410.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.35 / $76.14 / $151.81
| Professional | | $52.35 | $76.14 | $151.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.09 / $0.09 / $0.09
| Professional | | $0.09 | $0.09 | $0.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.43 / $100.00 / $390.73
| Facility | | $51.43 | $100.00 | $390.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.68 / $63.47 / $127.28
| Professional | | $54.68 | $63.47 | $127.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.91 / $63.47 / $104.37
| Professional | | $54.91 | $63.47 | $104.37 |