- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.20 / $61.20 / $77.26
| Professional | | $61.20 | $61.20 | $77.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.88 / $102.72 / $104.04
| Professional | | $86.88 | $102.72 | $104.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.75 / $85.60 / $107.63
| Professional | | $84.75 | $85.60 | $107.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.20 / $77.26 / $92.92
| Facility | | $61.20 | $77.26 | $92.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.11 / $37.02 / $482.28
| Professional | | $29.11 | $37.02 | $482.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $28.54 / $29.11 / $73.06
| Professional | | $28.54 | $29.11 | $73.06 |