- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.48 / $813.26 / $813.26
| Professional | | $234.48 | $813.26 | $813.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.47 / $261.06 / $261.06
| Facility | | $166.47 | $261.06 | $261.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.47 / $212.31 / $261.06
| Professional | | $166.47 | $212.31 | $261.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.86 / $248.63 / $261.06
| Facility | | $117.86 | $248.63 | $261.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.47 / $195.94 / $261.25
| Professional | | $166.47 | $195.94 | $261.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.32 / $105.47 / $162.52
| Professional | | $95.32 | $105.47 | $162.52 |