- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $112.20 / $363.08
| Facility | | $107.15 | $112.20 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $112.20 / $363.08
| Professional | | $112.20 | $112.20 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $32.36 / $54.95
| Professional | | $15.85 | $32.36 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Facility | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $181.97 / $213.80
| Professional | | $42.66 | $181.97 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $61.66 / $61.66
| Professional | | $61.66 | $61.66 | $61.66 |