- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $123.03 / $363.08
| Professional | | $93.33 | $123.03 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $144.54 / $144.54
| Professional | | $107.15 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $630.96
| Professional | | $123.03 | $123.03 | $630.96 |