- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $106.97
| Professional | | $106.97 | $106.97 | $106.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.87 / $42.87 / $100.91
| Facility | | $42.87 | $42.87 | $100.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.44 / $106.97 / $106.97
| Professional | | $71.44 | $106.97 | $106.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.87 / $42.87 / $100.91
| Facility | | $42.87 | $42.87 | $100.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.44 / $106.97 / $111.00
| Professional | | $71.44 | $106.97 | $111.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.97 / $106.97 / $320.91
| Professional | | $106.97 | $106.97 | $320.91 |