- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.19 / $107.19 / $107.19
| Professional | | $107.19 | $107.19 | $107.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.88 / $240.50 / $386.25
| Professional | | $26.88 | $240.50 | $386.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.93 / $234.42 / $371.64
| Professional | | $132.93 | $234.42 | $371.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.66 / $164.78 / $288.32
| Professional | | $131.66 | $164.78 | $288.32 |