- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.23 / $323.35 / $369.55
| Professional | | $280.23 | $323.35 | $369.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.73 / $375.73 / $383.66
| Facility | | $375.73 | $375.73 | $383.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.27 / $375.73 / $526.58
| Professional | | $274.27 | $375.73 | $526.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.73 / $375.73 / $383.66
| Facility | | $375.73 | $375.73 | $383.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.27 / $383.66 / $526.58
| Professional | | $274.27 | $383.66 | $526.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.01 / $366.46 / $663.21
| Professional | | $178.01 | $366.46 | $663.21 |