- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.51 / $281.51 / $369.88
| Professional | | $281.51 | $281.51 | $369.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.12 / $522.12 / $522.12
| Facility | | $522.12 | $522.12 | $522.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.12 / $522.12 / $522.12
| Professional | | $522.12 | $522.12 | $522.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.12 / $522.12 / $522.12
| Facility | | $522.12 | $522.12 | $522.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.35 / $480.93 / $733.14
| Professional | | $183.35 | $480.93 | $733.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.10 / $464.66 / $790.72
| Professional | | $376.10 | $464.66 | $790.72 |