- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.85 / $138.85 / $173.56
| Professional | | $138.85 | $138.85 | $173.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.23 / $131.11 / $442.12
| Facility | | $73.23 | $131.11 | $442.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $303.05 / $303.05
| Professional | | $75.00 | $303.05 | $303.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.78 / $103.00 / $121.58
| Facility | | $73.78 | $103.00 | $121.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.78 / $94.00 / $133.06
| Professional | | $73.78 | $94.00 | $133.06 |