- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.61 / $500.37 / $500.37
| Professional | | $373.61 | $500.37 | $500.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.13 / $278.13 / $278.13
| Facility | | $278.13 | $278.13 | $278.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.03 / $278.13 / $286.47
| Professional | | $203.03 | $278.13 | $286.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $278.13 / $278.13 / $278.13
| Facility | | $278.13 | $278.13 | $278.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.13 / $278.13 / $286.47
| Professional | | $278.13 | $278.13 | $286.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.75 / $533.73 / $703.44
| Professional | | $272.75 | $533.73 | $703.44 |