- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.44 / $255.44 / $294.74
| Professional | | $255.44 | $255.44 | $294.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.11 / $246.11 / $384.73
| Facility | | $246.11 | $246.11 | $384.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.66 / $246.10 / $262.36
| Professional | | $179.66 | $246.10 | $262.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.11 / $246.11 / $384.73
| Facility | | $246.11 | $246.11 | $384.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.66 / $246.10 / $262.36
| Professional | | $179.66 | $246.10 | $262.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.41 / $310.07 / $605.13
| Professional | | $178.41 | $310.07 | $605.13 |