- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.60 / $381.92 / $381.92
| Professional | | $215.60 | $381.92 | $381.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.41 / $360.01 / $716.00
| Professional | | $151.41 | $360.01 | $716.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $515.52 / $515.52 / $515.52
| Facility | | $515.52 | $515.52 | $515.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.41 / $360.01 / $716.00
| Professional | | $151.41 | $360.01 | $716.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.53 / $184.80 / $711.60
| Professional | | $134.53 | $184.80 | $711.60 |