- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.22 / $127.22 / $349.71
| Professional | | $127.22 | $127.22 | $349.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.81 / $106.76 / $182.58
| Facility | | $72.81 | $106.76 | $182.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.70 / $36.70 / $36.70
| Professional | | $36.70 | $36.70 | $36.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.22 / $139.94 / $261.88
| Facility | | $127.22 | $139.94 | $261.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |