- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.76 / $64.76 / $68.81
| Professional | | $64.76 | $64.76 | $68.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.04 / $36.04 / $38.72
| Facility | | $36.04 | $36.04 | $38.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.02 / $68.81 / $68.81
| Professional | | $42.02 | $68.81 | $68.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $275.00
| Professional | | $150.00 | $150.00 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.76 / $72.53 / $321.04
| Facility | | $64.76 | $72.53 | $321.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.32 / $325.32 / $325.32
| Professional | | $325.32 | $325.32 | $325.32 |