- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $209.33 / $231.96
| Professional | | $198.02 | $209.33 | $231.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.86 / $333.18 / $347.94
| Facility | | $299.86 | $333.18 | $347.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.82 / $374.82 / $374.82
| Professional | | $374.82 | $374.82 | $374.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.46 / $339.46 / $339.46
| Facility | | $339.46 | $339.46 | $339.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $282.88 / $452.61
| Professional | | $118.81 | $282.88 | $452.61 |