- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $347.36 / $383.55
| Professional | | $165.83 | $347.36 | $383.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.13 / $711.21 / $822.39
| Facility | | $364.13 | $711.21 | $822.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.51 / $364.13 / $364.13
| Professional | | $309.51 | $364.13 | $364.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.73 / $409.07 / $409.07
| Facility | | $373.73 | $409.07 | $409.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.71 / $409.07 / $409.07
| Professional | | $347.71 | $409.07 | $409.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $291.58 / $434.20
| Professional | | $169.82 | $291.58 | $434.20 |