- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.05 / $182.05 / $210.06
| Professional | | $182.05 | $182.05 | $210.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.20 / $291.02 / $291.02
| Facility | | $274.20 | $291.02 | $291.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.45 / $291.02 / $310.26
| Professional | | $212.45 | $291.02 | $310.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $274.20 / $291.02 / $291.02
| Facility | | $274.20 | $291.02 | $291.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.45 / $291.02 / $310.26
| Professional | | $212.45 | $291.02 | $310.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.46 / $184.46 / $232.64
| Facility | | $184.46 | $184.46 | $232.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.05 / $280.36 / $310.19
| Professional | | $168.05 | $280.36 | $310.19 |