- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $20.00 / $22.00
| Professional | | $10.58 | $20.00 | $22.00 |
- 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
- $306.10 / $306.10 / $306.10
| Facility | | $306.10 | $306.10 | $306.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.44 / $204.44 / $255.54
| Professional | | $204.44 | $204.44 | $255.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.07 / $751.07 / $751.07
| Professional | | $751.07 | $751.07 | $751.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.58 / $20.00 / $23.00
| Professional | | $10.58 | $20.00 | $23.00 |