- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.83 / $586.16 / $586.16
| Professional | | $104.83 | $586.16 | $586.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.18 / $177.76 / $269.38
| Facility | | $132.18 | $177.76 | $269.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.41 / $131.13 / $132.18
| Professional | | $61.41 | $131.13 | $132.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.18 / $154.97 / $269.38
| Facility | | $132.18 | $154.97 | $269.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.04 / $82.04 / $132.18
| Professional | | $82.04 | $82.04 | $132.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.29 / $38.29 / $125.30
| Professional | | $38.29 | $38.29 | $125.30 |