- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.88 / $157.88 / $182.18
| Professional | | $157.88 | $157.88 | $182.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.77 / $261.77 / $261.77
| Professional | | $261.77 | $261.77 | $261.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.81 / $268.08 / $268.08
| Facility | | $237.81 | $268.08 | $268.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.70 / $256.05 / $285.79
| Professional | | $195.70 | $256.05 | $285.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $237.81 / $268.08 / $268.08
| Facility | | $237.81 | $268.08 | $268.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.70 / $268.08 / $285.79
| Professional | | $195.70 | $268.08 | $285.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.75 / $243.16 / $374.06
| Professional | | $145.75 | $243.16 | $374.06 |