- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.98 / $414.98 / $414.98
| Professional | | $414.98 | $414.98 | $414.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.90 / $101.75 / $307.42
| Facility | | $80.90 | $101.75 | $307.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.73 / $94.64 / $182.81
| Professional | | $74.73 | $94.64 | $182.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.90 / $101.75 / $307.42
| Facility | | $80.90 | $101.75 | $307.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.52 / $89.30 / $133.16
| Professional | | $59.52 | $89.30 | $133.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $66.73 / $327.00 / $675.62
| Professional | | $66.73 | $327.00 | $675.62 |