- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.54 / $350.27 / $350.27
| Professional | | $261.54 | $350.27 | $350.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.62 / $327.62 / $327.62
| Facility | | $327.62 | $327.62 | $327.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.48 / $327.62 / $337.45
| Professional | | $278.48 | $327.62 | $337.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.62 / $327.62 / $327.62
| Facility | | $327.62 | $327.62 | $327.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.62 / $327.62 / $337.45
| Professional | | $327.62 | $327.62 | $337.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.63 / $381.61 / $542.40
| Professional | | $152.63 | $381.61 | $542.40 |