- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.36 / $273.36 / $315.42
| Professional | | $273.36 | $273.36 | $315.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $411.73
| Facility | | $373.38 | $373.38 | $411.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.85 / $317.37 / $317.37
| Professional | | $261.85 | $317.37 | $317.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $411.73
| Facility | | $373.38 | $373.38 | $411.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.85 / $317.37 / $317.37
| Professional | | $261.85 | $317.37 | $317.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.32 / $331.83 / $647.60
| Professional | | $186.32 | $331.83 | $647.60 |