- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.56 / $79.25 / $320.85
| Professional | | $69.56 | $79.25 | $320.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $336.56 / $567.53 / $657.36
| Facility | | $336.56 | $567.53 | $657.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.08 / $336.56 / $336.56
| Professional | | $286.08 | $336.56 | $336.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.94 / $350.59 / $1,225.80
| Professional | | $138.94 | $350.59 | $1,225.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.59 / $99.44 / $323.13
| Professional | | $72.59 | $99.44 | $323.13 |