- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.47 / $132.97 / $152.91
| Professional | | $129.47 | $132.97 | $152.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $409.07 / $409.07 / $409.07
| Facility | | $409.07 | $409.07 | $409.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.71 / $347.71 / $409.07
| Professional | | $347.71 | $347.71 | $409.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.88 / $318.88 / $318.88
| Facility | | $318.88 | $318.88 | $318.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.87 / $310.25 / $441.54
| Professional | | $176.87 | $310.25 | $441.54 |