- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.43 / $128.32 / $128.32
| Professional | | $96.43 | $128.32 | $128.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.58 / $93.34 / $172.13
| Facility | | $60.58 | $93.34 | $172.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.60 / $62.60 / $62.60
| Professional | | $62.60 | $62.60 | $62.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.47 / $158.47 / $158.47
| Facility | | $158.47 | $158.47 | $158.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.55 / $127.50 / $451.02
| Professional | | $57.55 | $127.50 | $451.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.90 / $175.59 / $470.02
| Professional | | $77.90 | $175.59 | $470.02 |