- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.42 / $288.05 / $470.62
| Professional | | $183.42 | $288.05 | $470.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $481.63 / $481.63 / $481.63
| Facility | | $481.63 | $481.63 | $481.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.63 / $481.63 / $481.63
| Professional | | $481.63 | $481.63 | $481.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.04 / $271.48 / $502.99
| Facility | | $124.04 | $271.48 | $502.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.16 / $377.24 / $552.35
| Professional | | $147.16 | $377.24 | $552.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.19 / $512.71 / $651.61
| Professional | | $443.19 | $512.71 | $651.61 |