- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.94 / $168.87 / $282.66
| Professional | | $140.94 | $168.87 | $282.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.36 / $204.69 / $491.39
| Facility | | $141.36 | $204.69 | $491.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.50 / $185.20 / $249.30
| Professional | | $102.50 | $185.20 | $249.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.74 / $388.68 / $538.66
| Facility | | $303.74 | $388.68 | $538.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.00 / $693.00 / $693.00
| Professional | | $693.00 | $693.00 | $693.00 |