- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.98 / $102.98 / $128.72
| Professional | | $102.98 | $102.98 | $128.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $62.00 / $187.26
| Facility | | $1.00 | $62.00 | $187.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.57 / $84.13 / $206.48
| Professional | | $57.57 | $84.13 | $206.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $121.26 / $201.66
| Facility | | $1.00 | $121.26 | $201.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.84 / $84.66 / $189.36
| Professional | | $54.84 | $84.66 | $189.36 |