- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.56 / $232.54 / $232.54
| Professional | | $109.56 | $232.54 | $232.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $52.87 / $77.51 / $133.62
| Facility | | $52.87 | $77.51 | $133.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.50 / $43.50 / $43.50
| Professional | | $43.50 | $43.50 | $43.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.31 / $244.17 / $395.32
| Facility | | $182.31 | $244.17 | $395.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |