- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.52 / $68.52 / $411.26
| Professional | | $68.52 | $68.52 | $411.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.04 / $107.04 / $107.04
| Facility | | $107.04 | $107.04 | $107.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.52 / $143.52 / $143.52
| Professional | | $143.52 | $143.52 | $143.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.04 / $107.04 / $107.04
| Facility | | $107.04 | $107.04 | $107.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.57 / $41.57 / $143.52
| Professional | | $41.57 | $41.57 | $143.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.94 / $63.96 / $287.82
| Professional | | $27.94 | $63.96 | $287.82 |