- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.25 / $135.25 / $317.30
| Professional | | $135.25 | $135.25 | $317.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.60 / $262.60 / $262.60
| Professional | | $262.60 | $262.60 | $262.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $193.40
| Facility | | $193.40 | $193.40 | $193.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $201.76
| Professional | | $193.40 | $193.40 | $201.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.10 / $130.13 / $324.16
| Professional | | $17.10 | $130.13 | $324.16 |