- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.78 / $217.50 / $217.50
| Professional | | $122.78 | $217.50 | $217.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $205.08 / $407.87
| Professional | | $86.25 | $205.08 | $407.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $205.08 / $407.87
| Professional | | $86.25 | $205.08 | $407.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.61 / $179.25 / $789.30
| Professional | | $76.61 | $179.25 | $789.30 |