- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.19 / $367.54 / $367.54
| Professional | | $50.19 | $367.54 | $367.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.81 / $101.64 / $101.64
| Facility | | $61.81 | $101.64 | $101.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.81 / $82.66 / $101.64
| Professional | | $61.81 | $82.66 | $101.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.26 / $96.80 / $101.64
| Facility | | $53.26 | $96.80 | $101.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.81 / $76.28 / $111.32
| Professional | | $61.81 | $76.28 | $111.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.08 / $47.66 / $54.56
| Professional | | $43.08 | $47.66 | $54.56 |