- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.65 / $230.50 / $274.56
| Professional | | $150.65 | $230.50 | $274.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.60 / $358.60 / $426.25
| Facility | | $358.60 | $358.60 | $426.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $322.74 / $358.60 / $538.78
| Professional | | $322.74 | $358.60 | $538.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.65 / $274.56 / $426.25
| Facility | | $150.65 | $274.56 | $426.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.60 / $358.60 / $538.78
| Professional | | $358.60 | $358.60 | $538.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.34 / $190.88 / $385.99
| Professional | | $185.34 | $190.88 | $385.99 |