- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.86 / $239.86 / $275.83
| Professional | | $239.86 | $239.86 | $275.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Facility | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.38 / $263.38 / $263.38
| Professional | | $263.38 | $263.38 | $263.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.39 / $239.86 / $343.00
| Facility | | $58.39 | $239.86 | $343.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $64.48 / $64.48 / $64.48
| Professional | | $64.48 | $64.48 | $64.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.42 / $310.42 / $317.48
| Professional | | $310.42 | $310.42 | $317.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.73 / $282.19 / $329.22
| Professional | | $265.73 | $282.19 | $329.22 |