- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.46 / $101.86 / $158.81
| Professional | | $89.46 | $101.86 | $158.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.54 / $118.54 / $118.54
| Facility | | $118.54 | $118.54 | $118.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.16 / $142.38 / $286.52
| Professional | | $97.16 | $142.38 | $286.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.00 / $143.00 / $143.00
| Facility | | $143.00 | $143.00 | $143.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.72 / $166.55 / $363.95
| Professional | | $130.72 | $166.55 | $363.95 |