- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.73 / $116.00 / $128.54
| Professional | | $109.73 | $116.00 | $128.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.16 / $184.62 / $192.80
| Facility | | $166.16 | $184.62 | $192.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.69 / $207.69 / $207.69
| Professional | | $207.69 | $207.69 | $207.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.10 / $188.10 / $188.10
| Facility | | $188.10 | $188.10 | $188.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.84 / $94.05 / $226.08
| Professional | | $65.84 | $94.05 | $226.08 |