- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.72 / $111.34 / $220.26
| Professional | | $75.72 | $111.34 | $220.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.72 / $95.72 / $114.30
| Professional | | $95.72 | $95.72 | $114.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.72 / $142.87 / $220.26
| Facility | | $75.72 | $142.87 | $220.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.65 / $67.09 / $711.49
| Professional | | $57.65 | $67.09 | $711.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.65 / $67.09 / $111.81
| Professional | | $57.65 | $67.09 | $111.81 |