- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.15 / $232.15 / $241.52
| Professional | | $232.15 | $232.15 | $241.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $258.98
| Facility | | $193.40 | $193.40 | $258.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.77 / $193.40 / $326.25
| Professional | | $23.77 | $193.40 | $326.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.60 / $161.54 / $197.47
| Professional | | $91.60 | $161.54 | $197.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.10 / $30.16 / $306.48
| Professional | | $17.10 | $30.16 | $306.48 |