- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.45 / $260.45 / $407.26
| Professional | | $260.45 | $260.45 | $407.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.20 / $454.20 / $454.20
| Facility | | $454.20 | $454.20 | $454.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.20 / $454.20 / $454.20
| Professional | | $454.20 | $454.20 | $454.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $290.63 / $290.63 / $577.47
| Facility | | $290.63 | $290.63 | $577.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.16 / $212.16 / $290.63
| Professional | | $212.16 | $212.16 | $290.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.72 / $232.04 / $257.61
| Professional | | $209.72 | $232.04 | $257.61 |