- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.31 / $39.31 / $39.31
| Professional | | $39.31 | $39.31 | $39.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.09 / $128.03 / $503.48
| Facility | | $37.09 | $128.03 | $503.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.31 / $39.31 / $128.03
| Professional | | $39.31 | $39.31 | $128.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.09 / $128.03 / $503.48
| Facility | | $37.09 | $128.03 | $503.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.31 / $39.31 / $128.03
| Professional | | $39.31 | $39.31 | $128.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.31 / $39.31 / $117.93
| Professional | | $39.31 | $39.31 | $117.93 |