- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.90 / $131.72 / $132.65
| Professional | | $91.90 | $131.72 | $132.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.00 / $15.00 / $43.00
| Professional | | $15.00 | $15.00 | $43.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.76 / $56.76 / $151.33
| Professional | | $56.76 | $56.76 | $151.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.72 / $132.65 / $212.24
| Facility | | $131.72 | $132.65 | $212.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $251.00 / $329.00
| Professional | | $155.00 | $251.00 | $329.00 |