- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.43 / $195.22 / $237.30
| Professional | | $190.43 | $195.22 | $237.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.87 / $585.87 / $585.87
| Facility | | $585.87 | $585.87 | $585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.23 / $120.56 / $379.85
| Professional | | $117.23 | $120.56 | $379.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $585.87 / $585.87 / $585.87
| Facility | | $585.87 | $585.87 | $585.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.10 / $119.63 / $379.85
| Professional | | $115.10 | $119.63 | $379.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.79 / $342.60 / $1,179.68
| Professional | | $121.79 | $342.60 | $1,179.68 |