- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.20 / $264.20 / $462.69
| Professional | | $264.20 | $264.20 | $462.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $516.02 / $516.02 / $516.02
| Facility | | $516.02 | $516.02 | $516.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.02 / $516.02 / $516.02
| Professional | | $516.02 | $516.02 | $516.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.77 / $293.77 / $515.02
| Facility | | $293.77 | $293.77 | $515.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.45 / $214.45 / $293.77
| Professional | | $214.45 | $214.45 | $293.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.73 / $281.38 / $325.19
| Professional | | $190.73 | $281.38 | $325.19 |