- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.31 / $369.56 / $604.17
| Professional | | $235.31 | $369.56 | $604.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.87 / $618.87 / $618.87
| Facility | | $618.87 | $618.87 | $618.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.87 / $618.87 / $618.87
| Professional | | $618.87 | $618.87 | $618.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.59 / $364.61 / $664.60
| Facility | | $236.59 | $364.61 | $664.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.87 / $618.87 / $824.88
| Professional | | $618.87 | $618.87 | $824.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.51 / $657.85 / $836.07
| Professional | | $548.51 | $657.85 | $836.07 |