- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.64 / $83.47 / $83.47
| Professional | | $61.64 | $83.47 | $83.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $18.00 / $18.00 / $18.00
| Facility | | $18.00 | $18.00 | $18.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.10 / $18.89 / $24.30
| Professional | | $17.10 | $18.89 | $24.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.20 / $385.20 / $385.20
| Professional | | $385.20 | $385.20 | $385.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.64 / $83.47 / $83.47
| Professional | | $61.64 | $83.47 | $83.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $50.00
| Professional | | $30.00 | $30.00 | $50.00 |