- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.10 / $912.60 / $912.60
| Professional | | $280.10 | $912.60 | $912.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $547.05 / $547.05 / $547.05
| Facility | | $547.05 | $547.05 | $547.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.05 / $547.05 / $547.05
| Professional | | $547.05 | $547.05 | $547.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.38 / $373.38 / $462.17
| Facility | | $373.38 | $373.38 | $462.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.37 / $317.37 / $417.09
| Professional | | $317.37 | $317.37 | $417.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.44 / $209.60 / $322.99
| Professional | | $189.44 | $209.60 | $322.99 |