- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.03 / $318.86 / $318.86
| Professional | | $57.03 | $318.86 | $318.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.91 / $84.30 / $282.66
| Facility | | $71.91 | $84.30 | $282.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.91 / $71.91 / $71.91
| Professional | | $71.91 | $71.91 | $71.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $71.91 / $84.30 / $282.66
| Facility | | $71.91 | $84.30 | $282.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.63 / $44.63 / $71.91
| Professional | | $44.63 | $44.63 | $71.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $20.83 / $20.83 / $49.59
| Professional | | $20.83 | $20.83 | $49.59 |