- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.66 / $460.18 / $513.87
| Professional | | $335.66 | $460.18 | $513.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.47 / $164.47 / $164.47
| Facility | | $164.47 | $164.47 | $164.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $510.20 / $510.20 / $510.20
| Professional | | $510.20 | $510.20 | $510.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.00 / $128.00 / $128.00
| Facility | | $128.00 | $128.00 | $128.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.80 / $128.00 / $348.75
| Professional | | $108.80 | $128.00 | $348.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.22 / $357.67 / $652.80
| Professional | | $268.22 | $357.67 | $652.80 |