- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.25 / $275.62 / $401.08
| Professional | | $206.25 | $275.62 | $401.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.92 / $302.92 / $302.92
| Facility | | $302.92 | $302.92 | $302.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.92 / $302.92 / $302.92
| Professional | | $302.92 | $302.92 | $302.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.45 / $263.45 / $371.64
| Facility | | $263.45 | $263.45 | $371.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.93 / $223.93 / $297.51
| Professional | | $223.93 | $223.93 | $297.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.72 / $220.01 / $471.45
| Professional | | $125.72 | $220.01 | $471.45 |