- 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
- $163.98 / $505.25 / $505.25
| Facility | | $163.98 | $505.25 | $505.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.00 / $62.00 / $62.00
| Professional | | $62.00 | $62.00 | $62.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.25 / $121.26 / $201.66
| Facility | | $80.25 | $121.26 | $201.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.00 / $86.10 / $206.48
| Professional | | $62.00 | $86.10 | $206.48 |