- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.76 / $243.18 / $326.95
| Professional | | $197.76 | $243.18 | $326.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $258.98
| Facility | | $193.40 | $193.40 | $258.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.39 / $193.40 / $326.25
| Professional | | $164.39 | $193.40 | $326.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $539.74 / $539.74 / $539.74
| Professional | | $539.74 | $539.74 | $539.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.68 / $247.68 / $247.68
| Professional | | $247.68 | $247.68 | $247.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.57 / $110.40 / $243.50
| Professional | | $18.57 | $110.40 | $243.50 |