- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.58 / $68.58 / $68.58
| Professional | | $68.58 | $68.58 | $68.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $288.75
| Professional | | $18.44 | $153.77 | $288.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.64 / $105.46 / $170.63
| Professional | | $79.64 | $105.46 | $170.63 |