- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $218.78 / $263.03
| Professional | | $77.62 | $218.78 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $398.11 / $524.81
| Professional | | $177.83 | $398.11 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $257.04 / $354.81
| Professional | | $257.04 | $257.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.61 / $158.49 / $691.83
| Professional | | $67.61 | $158.49 | $691.83 |