- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $208.93 / $263.03
| Professional | | $147.91 | $208.93 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $1,318.26
| Professional | | $114.82 | $114.82 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $120.23 / $158.49
| Professional | | $107.15 | $120.23 | $158.49 |