- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.39 / $297.62 / $522.14
| Professional | | $260.39 | $297.62 | $522.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $383.88 / $383.88 / $383.88
| Facility | | $383.88 | $383.88 | $383.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.88 / $383.88 / $383.88
| Professional | | $383.88 | $383.88 | $383.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.53 / $331.53 / $469.20
| Facility | | $331.53 | $331.53 | $469.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.80 / $331.53 / $374.14
| Professional | | $281.80 | $331.53 | $374.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.72 / $238.09 / $483.71
| Professional | | $158.72 | $238.09 | $483.71 |