- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.86 / $373.80 / $373.80
| Professional | | $268.86 | $373.80 | $373.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.64 / $407.81 / $407.81
| Professional | | $346.64 | $407.81 | $407.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Professional | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.71 / $312.77 / $469.28
| Professional | | $187.71 | $312.77 | $469.28 |