- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.98 / $30.98 / $38.72
| Professional | | $30.98 | $30.98 | $38.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.53 / $24.76 / $60.66
| Facility | | $13.53 | $24.76 | $60.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.24 / $2,035.24 / $2,035.24
| Professional | | $2,035.24 | $2,035.24 | $2,035.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.35 / $155.35 / $155.35
| Facility | | $155.35 | $155.35 | $155.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $13.53 / $17.85 / $59.54
| Facility | | $13.53 | $17.85 | $59.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,035.24 / $2,035.24 / $2,035.24
| Professional | | $2,035.24 | $2,035.24 | $2,035.24 |