- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.88 / $52.88 / $66.09
| Professional | | $52.88 | $52.88 | $66.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.67 / $116.67 / $116.67
| Facility | | $116.67 | $116.67 | $116.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.53 / $231.53 / $231.53
| Professional | | $231.53 | $231.53 | $231.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.66 / $74.44 / $74.44
| Professional | | $44.66 | $74.44 | $74.44 |