- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.26 / $234.26 / $301.30
| Professional | | $234.26 | $234.26 | $301.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.57 / $373.57 / $373.57
| Facility | | $373.57 | $373.57 | $373.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.70 / $272.70 / $373.57
| Professional | | $272.70 | $272.70 | $373.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.45 / $276.36 / $276.36
| Facility | | $0.45 | $276.36 | $276.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.19 / $283.97 / $427.77
| Professional | | $253.19 | $283.97 | $427.77 |