- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.13 / $203.13 / $355.74
| Professional | | $203.13 | $203.13 | $355.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.74 / $396.74 / $396.74
| Facility | | $396.74 | $396.74 | $396.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.74 / $396.74 / $396.74
| Professional | | $396.74 | $396.74 | $396.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.67 / $280.67 / $446.89
| Facility | | $280.67 | $280.67 | $446.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.89 / $204.89 / $280.67
| Professional | | $204.89 | $204.89 | $280.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.19 / $202.68 / $312.33
| Professional | | $183.19 | $202.68 | $312.33 |