- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.04 / $260.10 / $325.92
| Professional | | $227.04 | $260.10 | $325.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.20 / $51.20 / $51.20
| Facility | | $51.20 | $51.20 | $51.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.40 / $32.40 / $32.40
| Professional | | $32.40 | $32.40 | $32.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.34 / $240.34 / $407.95
| Facility | | $240.34 | $240.34 | $407.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.42 / $240.34 / $240.34
| Professional | | $33.42 | $240.34 | $240.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.72 / $208.08 / $397.31
| Professional | | $138.72 | $208.08 | $397.31 |