- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $354.81 / $426.58
| Professional | | $295.12 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.18 / $83.18 / $83.18
| Professional | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $158.49 / $173.78
| Professional | | $52.48 | $158.49 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $537.03 / $537.03
| Professional | | $537.03 | $537.03 | $537.03 |