- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.38 / $54.38 / $67.97
| Professional | | $54.38 | $54.38 | $67.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.40 / $508.40 / $508.40
| Facility | | $508.40 | $508.40 | $508.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.00 / $102.00 / $102.00
| Professional | | $102.00 | $102.00 | $102.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.88 / $114.88 / $128.66
| Facility | | $114.88 | $114.88 | $128.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.54 / $128.66 / $196.77
| Professional | | $105.54 | $128.66 | $196.77 |