- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.71 / $213.71 / $374.26
| Professional | | $213.71 | $213.71 | $374.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.40 / $417.40 / $417.40
| Facility | | $417.40 | $417.40 | $417.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.40 / $417.40 / $417.40
| Professional | | $417.40 | $417.40 | $417.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.52 / $299.52 / $574.71
| Facility | | $299.52 | $299.52 | $574.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.65 / $218.65 / $299.52
| Professional | | $218.65 | $218.65 | $299.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.13 / $203.73 / $313.94
| Professional | | $184.13 | $203.73 | $313.94 |