- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.24 / $119.10 / $579.22
| Professional | | $95.24 | $119.10 | $579.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.25 / $170.25 / $197.11
| Facility | | $170.25 | $170.25 | $197.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $109.75 / $183.14
| Professional | | $77.00 | $109.75 | $183.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.00 / $114.33 / $379.83
| Professional | | $77.00 | $114.33 | $379.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.75 / $119.97 / $450.50
| Professional | | $82.75 | $119.97 | $450.50 |