- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.58 / $206.58 / $238.37
| Professional | | $206.58 | $206.58 | $238.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.27 / $218.27 / $311.14
| Facility | | $218.27 | $218.27 | $311.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $218.27 / $224.82
| Professional | | $159.34 | $218.27 | $224.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.27 / $218.27 / $311.14
| Facility | | $218.27 | $218.27 | $311.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.34 / $218.27 / $224.82
| Professional | | $159.34 | $218.27 | $224.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.84 / $318.14 / $351.98
| Professional | | $152.84 | $318.14 | $351.98 |