- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.36 / $51.80 / $54.51
| Professional | | $51.36 | $51.80 | $54.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.35 / $587.92 / $649.07
| Facility | | $494.35 | $587.92 | $649.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.28 / $63.25 / $63.25
| Professional | | $44.28 | $63.25 | $63.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,242.49 / $1,242.49 / $1,242.49
| Facility | | $1,242.49 | $1,242.49 | $1,242.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.70 / $111.40 / $310.45
| Professional | | $52.70 | $111.40 | $310.45 |