- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.58 / $176.12 / $222.35
| Professional | | $165.58 | $176.12 | $222.35 |
- 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
- $91.88 / $141.65 / $436.57
| Professional | | $91.88 | $141.65 | $436.57 |
- 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
- $131.37 / $142.60 / $436.57
| Professional | | $131.37 | $142.60 | $436.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.37 / $282.77 / $630.69
| Professional | | $139.37 | $282.77 | $630.69 |