- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $389.05 / $562.34
| Professional | | $288.40 | $389.05 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Facility | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $234.42 / $239.88
| Professional | | $199.53 | $234.42 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $34.67 / $257.04 / $389.05
| Facility | | $34.67 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $229.09 / $338.84 / $575.44
| Professional | | $229.09 | $338.84 | $575.44 |