- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.64 / $213.64 / $374.15
| Professional | | $213.64 | $213.64 | $374.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $417.27 / $417.27 / $417.27
| Facility | | $417.27 | $417.27 | $417.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $417.27 / $417.27 / $417.27
| Professional | | $417.27 | $417.27 | $417.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $296.00 / $296.00 / $470.79
| Facility | | $296.00 | $296.00 | $470.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.08 / $216.08 / $296.00
| Professional | | $216.08 | $216.08 | $296.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.74 / $188.91 / $339.62
| Professional | | $170.74 | $188.91 | $339.62 |