- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.47 / $60.96 / $354.91
| Professional | | $48.47 | $60.96 | $354.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.74 / $116.74 / $116.74
| Professional | | $116.74 | $116.74 | $116.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $62.72 / $125.52 / $125.52
| Facility | | $62.72 | $125.52 | $125.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.72 / $102.07 / $125.52
| Professional | | $62.72 | $102.07 | $125.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.44 / $119.54 / $125.52
| Facility | | $51.44 | $119.54 | $125.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.72 / $94.20 / $125.60
| Professional | | $62.72 | $94.20 | $125.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.60 / $46.03 / $73.00
| Professional | | $41.60 | $46.03 | $73.00 |