- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.35 / $204.74 / $204.74
| Professional | | $122.35 | $204.74 | $204.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.14 / $268.14 / $268.14
| Facility | | $268.14 | $268.14 | $268.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.32 / $136.16 / $416.23
| Professional | | $131.32 | $136.16 | $416.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $268.14 / $268.14 / $268.14
| Facility | | $268.14 | $268.14 | $268.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.02 / $136.16 / $416.23
| Professional | | $132.02 | $136.16 | $416.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.16 / $217.41 / $633.53
| Professional | | $141.16 | $217.41 | $633.53 |