- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $311.05 / $311.05 / $486.37
| Professional | | $311.05 | $311.05 | $486.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $542.42 / $542.42 / $542.42
| Facility | | $542.42 | $542.42 | $542.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.42 / $542.42 / $542.42
| Professional | | $542.42 | $542.42 | $542.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $324.30 / $324.30 / $570.90
| Facility | | $324.30 | $324.30 | $570.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.74 / $236.74 / $515.29
| Professional | | $236.74 | $236.74 | $515.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.02 / $258.92 / $287.45
| Professional | | $234.02 | $258.92 | $287.45 |