- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.20 / $101.20 / $101.20
| Professional | | $101.20 | $101.20 | $101.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $449.57 / $987.21 / $1,031.92
| Facility | | $449.57 | $987.21 | $1,031.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.48 / $66.48 / $83.12
| Professional | | $66.48 | $66.48 | $83.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $66.48 / $83.12
| Professional | | $45.00 | $66.48 | $83.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.79 / $44.10 / $113.43
| Professional | | $34.79 | $44.10 | $113.43 |