- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.82 / $304.52 / $390.19
| Professional | | $271.82 | $304.52 | $390.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $391.16 / $391.16 / $391.16
| Facility | | $391.16 | $391.16 | $391.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $391.16 / $391.16 / $391.16
| Professional | | $391.16 | $391.16 | $391.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $488.47
| Facility | | $307.55 | $307.55 | $488.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.42 / $261.42 / $353.87
| Professional | | $261.42 | $261.42 | $353.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.55 / $235.72 / $624.48
| Professional | | $141.55 | $235.72 | $624.48 |