- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.76 / $308.12 / $412.66
| Professional | | $239.76 | $308.12 | $412.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.09 / $376.09 / $376.09
| Facility | | $376.09 | $376.09 | $376.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.68 / $376.09 / $387.37
| Professional | | $319.68 | $376.09 | $387.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $376.09 / $376.09 / $376.09
| Facility | | $376.09 | $376.09 | $376.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.09 / $376.09 / $387.37
| Professional | | $376.09 | $376.09 | $387.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.86 / $466.67 / $639.01
| Professional | | $195.86 | $466.67 | $639.01 |