- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.52 / $294.20 / $558.32
| Professional | | $265.52 | $294.20 | $558.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.14 / $269.14 / $655.89
| Facility | | $269.14 | $269.14 | $655.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $269.14 / $269.14
| Professional | | $243.61 | $269.14 | $269.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.61 / $269.14 / $655.89
| Facility | | $243.61 | $269.14 | $655.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.29 / $264.29 / $310.26
| Professional | | $264.29 | $264.29 | $310.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |