- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.11 / $264.11 / $304.74
| Professional | | $264.11 | $264.11 | $304.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $410.22 / $482.61
| Professional | | $410.22 | $410.22 | $482.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.61 / $482.61 / $482.61
| Facility | | $482.61 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.22 / $482.61 / $482.61
| Professional | | $410.22 | $482.61 | $482.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.84 / $252.10 / $540.92
| Professional | | $100.84 | $252.10 | $540.92 |