- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.58 / $385.16 / $514.30
| Professional | | $360.58 | $385.16 | $514.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $53.34 / $104.18 / $120.47
| Facility | | $53.34 | $104.18 | $120.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.34 / $53.34 / $53.34
| Professional | | $45.34 | $53.34 | $53.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $356.59 / $356.59 / $356.59
| Facility | | $356.59 | $356.59 | $356.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.10 / $356.59 / $356.59
| Professional | | $303.10 | $356.59 | $356.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.95 / $385.93 / $694.60
| Professional | | $285.95 | $385.93 | $694.60 |