- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.15 / $101.50 / $101.50
| Professional | | $100.15 | $101.50 | $101.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $568.36 / $568.36 / $568.36
| Facility | | $568.36 | $568.36 | $568.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.19 / $132.19 / $447.62
| Professional | | $132.19 | $132.19 | $447.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.62 / $142.56 / $447.62
| Professional | | $131.62 | $142.56 | $447.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.62 / $142.56 / $447.62
| Professional | | $131.62 | $142.56 | $447.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.05 / $138.13 / $476.15
| Professional | | $96.05 | $138.13 | $476.15 |