- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.05 / $189.20 / $346.26
| Professional | | $128.05 | $189.20 | $346.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.34 / $240.34 / $240.34
| Facility | | $240.34 | $240.34 | $240.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.29 / $240.34 / $483.75
| Professional | | $204.29 | $240.34 | $483.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.63 / $511.63 / $511.63
| Professional | | $511.63 | $511.63 | $511.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.44 / $277.44 / $277.44
| Professional | | $277.44 | $277.44 | $277.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.28 / $218.70 / $285.37
| Professional | | $167.28 | $218.70 | $285.37 |