- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.58 / $291.48 / $488.43
| Professional | | $195.58 | $291.48 | $488.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.74 / $194.62 / $960.84
| Facility | | $132.74 | $194.62 | $960.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.40 / $419.40 / $884.25
| Professional | | $419.40 | $419.40 | $884.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.48 / $320.63 / $616.76
| Facility | | $291.48 | $320.63 | $616.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |