- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.62 / $122.62 / $122.62
| Professional | | $122.62 | $122.62 | $122.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $692.70 / $692.70 / $692.70
| Facility | | $692.70 | $692.70 | $692.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.88 / $183.59 / $432.85
| Professional | | $142.88 | $183.59 | $432.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.88 / $183.59 / $432.85
| Professional | | $142.88 | $183.59 | $432.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.44 / $197.40 / $284.06
| Professional | | $125.44 | $197.40 | $284.06 |