- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.85 / $219.85 / $1,578.16
| Professional | | $219.85 | $219.85 | $1,578.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $465.35
| Facility | | $354.55 | $354.55 | $465.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.37 / $354.55 / $617.63
| Professional | | $301.37 | $354.55 | $617.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.39 / $345.35 / $497.77
| Professional | | $237.39 | $345.35 | $497.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.85 / $272.36 / $488.55
| Professional | | $219.85 | $272.36 | $488.55 |