- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.25 / $222.25 / $322.26
| Professional | | $222.25 | $222.25 | $322.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.60 / $251.60 / $251.60
| Facility | | $251.60 | $251.60 | $251.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.67 / $304.61 / $507.68
| Facility | | $209.67 | $304.61 | $507.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.36 / $399.36 / $399.36
| Professional | | $399.36 | $399.36 | $399.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.67 / $304.61 / $507.68
| Facility | | $209.67 | $304.61 | $507.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.36 / $399.36 / $399.36
| Professional | | $399.36 | $399.36 | $399.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.14 / $427.88 / $658.21
| Professional | | $211.14 | $427.88 | $658.21 |