- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.62 / $284.62 / $355.78
| Professional | | $284.62 | $284.62 | $355.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.62 / $200.11 / $570.52
| Facility | | $150.62 | $200.11 | $570.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.84 / $641.84 / $641.84
| Professional | | $641.84 | $641.84 | $641.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.60 / $293.82 / $365.13
| Facility | | $249.60 | $293.82 | $365.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.60 / $293.82 / $365.13
| Professional | | $249.60 | $293.82 | $365.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.88 / $166.88 / $290.97
| Professional | | $166.88 | $166.88 | $290.97 |