- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.77 / $283.88 / $283.88
| Professional | | $38.77 | $283.88 | $283.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.48 / $107.00 / $107.00
| Facility | | $61.48 | $107.00 | $107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.48 / $87.00 / $107.00
| Professional | | $61.48 | $87.00 | $107.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.86 / $101.90 / $107.00
| Facility | | $54.86 | $101.90 | $107.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.48 / $80.31 / $107.08
| Professional | | $61.48 | $80.31 | $107.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.36 / $49.09 / $75.11
| Professional | | $44.36 | $49.09 | $75.11 |