- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.15 / $82.30 / $460.52
| Professional | | $75.15 | $82.30 | $460.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.20 / $319.20 / $359.72
| Professional | | $319.20 | $319.20 | $359.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $401.45 / $594.54 / $597.22
| Professional | | $401.45 | $594.54 | $597.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.54 / $401.45 / $597.22
| Professional | | $236.54 | $401.45 | $597.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.77 / $112.74 / $614.57
| Professional | | $75.77 | $112.74 | $614.57 |