- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.12 / $257.06 / $257.06
| Professional | | $145.12 | $257.06 | $257.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.98 / $346.98 / $346.98
| Facility | | $346.98 | $346.98 | $346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.86 / $242.18 / $481.66
| Professional | | $101.86 | $242.18 | $481.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.98 / $346.98 / $346.98
| Facility | | $346.98 | $346.98 | $346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.86 / $242.18 / $481.66
| Professional | | $101.86 | $242.18 | $481.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.55 / $282.83 / $932.90
| Professional | | $90.55 | $282.83 | $932.90 |