- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.38 / $471.77 / $471.77
| Professional | | $84.38 | $471.77 | $471.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.39 / $124.73 / $418.21
| Facility | | $106.39 | $124.73 | $418.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.72 / $106.39 / $106.39
| Professional | | $35.72 | $106.39 | $106.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.39 / $124.73 / $418.21
| Facility | | $106.39 | $124.73 | $418.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.03 / $66.03 / $106.39
| Professional | | $66.03 | $66.03 | $106.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.82 / $30.82 / $73.37
| Professional | | $30.82 | $30.82 | $73.37 |