- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.47 / $134.47 / $1,260.80
| Professional | | $134.47 | $134.47 | $1,260.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.75 / $59.44 / $151.47
| Facility | | $35.75 | $59.44 | $151.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.75 / $137.72 / $137.72
| Professional | | $35.75 | $137.72 | $137.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.75 / $59.44 / $151.47
| Facility | | $35.75 | $59.44 | $151.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.00 / $33.00 / $137.72
| Professional | | $22.00 | $33.00 | $137.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.91 / $153.91 / $153.91
| Professional | | $153.91 | $153.91 | $153.91 |