- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.52 / $128.15 / $157.90
| Professional | | $102.52 | $128.15 | $157.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.03 / $88.09 / $102.27
| Facility | | $55.03 | $88.09 | $102.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.20 / $318.20 / $318.20
| Professional | | $318.20 | $318.20 | $318.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $55.00
| Facility | | $55.00 | $55.00 | $55.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.21 / $97.24
| Professional | | $50.00 | $60.21 | $97.24 |