- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.00 / $36.00 / $36.00
| Professional | | $36.00 | $36.00 | $36.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.36 / $115.36 / $115.36
| Facility | | $115.36 | $115.36 | $115.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.30 / $79.30 / $99.12
| Professional | | $79.30 | $79.30 | $99.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.36 / $115.36 / $115.36
| Facility | | $115.36 | $115.36 | $115.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.67 / $79.30 / $99.12
| Professional | | $52.67 | $79.30 | $99.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.35 / $48.62 / $113.44
| Professional | | $41.35 | $48.62 | $113.44 |