- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.78 / $236.78 / $273.20
| Professional | | $236.78 | $236.78 | $273.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.00 / $251.00 / $356.63
| Facility | | $251.00 | $251.00 | $356.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.23 / $251.00 / $258.52
| Professional | | $183.23 | $251.00 | $258.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.00 / $251.00 / $356.63
| Facility | | $251.00 | $251.00 | $356.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.23 / $251.00 / $258.52
| Professional | | $183.23 | $251.00 | $258.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.78 / $345.78 / $345.78
| Facility | | $345.78 | $345.78 | $345.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.38 / $287.43 / $560.92
| Professional | | $161.38 | $287.43 | $560.92 |