- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.53 / $964.58 / $964.58
| Professional | | $231.53 | $964.58 | $964.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.72 / $289.72 / $344.38
| Facility | | $289.72 | $289.72 | $344.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $289.72 / $380.43
| Professional | | $173.78 | $289.72 | $380.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.72 / $325.64 / $344.38
| Facility | | $289.72 | $325.64 | $344.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $254.81 / $389.20
| Professional | | $173.78 | $254.81 | $389.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.02 / $320.63 / $384.30
| Professional | | $258.02 | $320.63 | $384.30 |