- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.55 / $564.66 / $2,102.66
| Professional | | $269.55 | $564.66 | $2,102.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $412.75 / $412.75 / $412.75
| Facility | | $412.75 | $412.75 | $412.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.95 / $412.75 / $672.79
| Professional | | $265.95 | $412.75 | $672.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.30 / $311.73 / $524.82
| Facility | | $206.30 | $311.73 | $524.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.75 / $490.65 / $763.81
| Professional | | $329.75 | $490.65 | $763.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.58 / $634.98 / $766.93
| Professional | | $523.58 | $634.98 | $766.93 |