- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.34 / $72.45 / $83.78
| Professional | | $65.34 | $72.45 | $83.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.03 / $35.03 / $35.03
| Professional | | $35.03 | $35.03 | $35.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.25 / $42.25 / $42.25
| Professional | | $42.25 | $42.25 | $42.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.34 / $73.73 / $105.34
| Facility | | $65.34 | $73.73 | $105.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.28 / $43.91 / $558.77
| Professional | | $29.28 | $43.91 | $558.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.28 / $42.54 / $56.23
| Professional | | $29.28 | $42.54 | $56.23 |