- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.70 / $206.70 / $247.65
| Professional | | $206.70 | $206.70 | $247.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.86 / $255.48 / $306.57
| Facility | | $237.86 | $255.48 | $306.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.66 / $616.66 / $616.66
| Professional | | $616.66 | $616.66 | $616.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.19 / $176.19 / $176.19
| Professional | | $176.19 | $176.19 | $176.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.90 / $244.90 / $244.90
| Facility | | $244.90 | $244.90 | $244.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.00 / $202.62 / $246.67
| Professional | | $185.00 | $202.62 | $246.67 |