- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.30 / $83.30 / $625.13
| Professional | | $83.30 | $83.30 | $625.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.71 / $162.71 / $162.71
| Facility | | $162.71 | $162.71 | $162.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.12 / $218.12 / $218.12
| Professional | | $218.12 | $218.12 | $218.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.71 / $162.71 / $162.71
| Facility | | $162.71 | $162.71 | $162.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.19 / $63.19 / $218.12
| Professional | | $63.19 | $63.19 | $218.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.47 / $97.22 / $224.62
| Professional | | $42.47 | $97.22 | $224.62 |