- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.75 / $131.47 / $606.79
| Professional | | $86.75 | $131.47 | $606.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.20 / $300.06 / $557.13
| Facility | | $106.20 | $300.06 | $557.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.00 / $591.10 / $1,209.40
| Professional | | $314.00 | $591.10 | $1,209.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.00 / $314.00 / $314.00
| Facility | | $314.00 | $314.00 | $314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.27 / $367.47 / $520.09
| Professional | | $96.27 | $367.47 | $520.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.80 / $517.50 / $755.30
| Professional | | $304.80 | $517.50 | $755.30 |