- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.41 / $277.41 / $433.76
| Professional | | $277.41 | $277.41 | $433.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $483.76 / $483.76 / $483.76
| Facility | | $483.76 | $483.76 | $483.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $483.76 / $483.76 / $483.76
| Professional | | $483.76 | $483.76 | $483.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.11 / $246.11 / $433.24
| Facility | | $246.11 | $246.11 | $433.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.66 / $179.66 / $246.10
| Professional | | $179.66 | $179.66 | $246.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.59 / $196.49 / $218.14
| Professional | | $177.59 | $196.49 | $218.14 |