- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.31 / $854.28 / $854.28
| Professional | | $246.31 | $854.28 | $854.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.76 / $233.17 / $233.17
| Facility | | $138.76 | $233.17 | $233.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.76 / $189.62 / $233.17
| Professional | | $138.76 | $189.62 | $233.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.81 / $222.07 / $233.17
| Facility | | $123.81 | $222.07 | $233.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.76 / $175.01 / $255.38
| Professional | | $138.76 | $175.01 | $255.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.13 / $110.79 / $175.71
| Professional | | $100.13 | $110.79 | $175.71 |