- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.32 / $136.63 / $168.37
| Professional | | $109.32 | $136.63 | $168.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.27 / $108.28 / $133.91
| Facility | | $66.27 | $108.28 | $133.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.24 / $416.24 / $416.24
| Professional | | $416.24 | $416.24 | $416.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.00 / $66.00 / $66.00
| Facility | | $66.00 | $66.00 | $66.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.00 / $74.01 / $118.38
| Professional | | $61.00 | $74.01 | $118.38 |