- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.38 / $253.38 / $292.37
| Professional | | $253.38 | $253.38 | $292.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.63 / $387.54 / $387.54
| Facility | | $381.63 | $387.54 | $387.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.89 / $387.54 / $399.17
| Professional | | $282.89 | $387.54 | $399.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.63 / $387.54 / $387.54
| Facility | | $381.63 | $387.54 | $387.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.89 / $387.54 / $399.17
| Professional | | $282.89 | $387.54 | $399.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.70 / $312.70 / $600.26
| Professional | | $172.70 | $312.70 | $600.26 |