- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $417.73
| Professional | | $243.61 | $243.61 | $417.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.77 / $275.77 / $275.77
| Facility | | $275.77 | $275.77 | $275.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.82 / $243.61 / $444.85
| Facility | | $229.82 | $243.61 | $444.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.82 / $243.61 / $444.85
| Facility | | $229.82 | $243.61 | $444.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.61 / $243.61 / $243.61
| Professional | | $243.61 | $243.61 | $243.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.43 / $243.61 / $253.35
| Professional | | $231.43 | $243.61 | $253.35 |