- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.98 / $126.97 / $212.54
| Professional | | $105.98 | $126.97 | $212.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $79.70 / $108.09 / $210.88
| Facility | | $79.70 | $108.09 | $210.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $70.09 / $96.40 / $173.80
| Professional | | $70.09 | $96.40 | $173.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.09 / $1,791.30 / $1,791.30
| Facility | | $155.09 | $1,791.30 | $1,791.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $385.00 / $385.00 / $385.00
| Professional | | $385.00 | $385.00 | $385.00 |