- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.15 / $106.15 / $950.88
| Professional | | $106.15 | $106.15 | $950.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Facility | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $382.13
| Professional | | $202.44 | $238.16 | $382.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.49 / $254.74 / $367.96
| Professional | | $175.49 | $254.74 | $367.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.15 / $164.42 / $235.88
| Professional | | $106.15 | $164.42 | $235.88 |