- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.06 / $291.76 / $356.09
| Professional | | $248.06 | $291.76 | $356.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.74 / $387.74 / $387.74
| Facility | | $387.74 | $387.74 | $387.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.74 / $387.74 / $387.74
| Professional | | $387.74 | $387.74 | $387.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.50 / $229.50 / $446.97
| Facility | | $229.50 | $229.50 | $446.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.08 / $229.50 / $330.17
| Professional | | $195.08 | $229.50 | $330.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.74 / $226.84 / $479.63
| Professional | | $148.74 | $226.84 | $479.63 |