- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.80 / $263.03 / $380.19
| Professional | | $213.80 | $263.03 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $338.84 / $478.63
| Professional | | $151.36 | $338.84 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $309.03 / $707.95
| Professional | | $134.90 | $309.03 | $707.95 |