- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $102.33
| Professional | | $83.18 | $83.18 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.12 / $77.62 / $1,778.28
| Facility | | $50.12 | $77.62 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $199.53 / $199.53
| Professional | | $50.12 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.57 / $64.57 / $64.57
| Professional | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.36 / $32.36 / $81.28
| Professional | | $32.36 | $32.36 | $81.28 |