- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.62 / $187.10 / $785.88
| Professional | | $105.62 | $187.10 | $785.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.56 / $204.56 / $204.56
| Facility | | $204.56 | $204.56 | $204.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $170.83 / $304.89
| Professional | | $71.84 | $170.83 | $304.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.56 / $204.56 / $204.56
| Facility | | $204.56 | $204.56 | $204.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $71.84 / $170.83 / $304.89
| Professional | | $71.84 | $170.83 | $304.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.39 / $171.11 / $282.38
| Professional | | $53.39 | $171.11 | $282.38 |