- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.03 / $131.19 / $278.77
| Professional | | $85.03 | $131.19 | $278.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.60 / $163.33 / $272.17
| Facility | | $41.60 | $163.33 | $272.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.84 / $41.60 / $48.36
| Professional | | $34.84 | $41.60 | $48.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.94 / $166.47 / $278.77
| Facility | | $157.94 | $166.47 | $278.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.91 / $631.91 / $631.91
| Professional | | $631.91 | $631.91 | $631.91 |