- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.25 / $214.26 / $335.01
| Professional | | $214.25 | $214.26 | $335.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.63 / $373.63 / $373.63
| Facility | | $373.63 | $373.63 | $373.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.63 / $373.63 / $373.63
| Professional | | $373.63 | $373.63 | $373.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.27 / $211.27 / $414.30
| Facility | | $211.27 | $211.27 | $414.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.22 / $154.22 / $211.27
| Professional | | $154.22 | $154.22 | $211.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.44 / $168.68 / $187.26
| Professional | | $152.44 | $168.68 | $187.26 |