- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.62 / $238.62 / $275.33
| Professional | | $238.62 | $238.62 | $275.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.54 / $305.54 / $359.40
| Facility | | $305.54 | $305.54 | $359.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.04 / $305.54 / $325.73
| Professional | | $223.04 | $305.54 | $325.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.54 / $305.54 / $359.40
| Facility | | $305.54 | $305.54 | $359.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.04 / $305.54 / $325.73
| Professional | | $223.04 | $305.54 | $325.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.40 / $244.40 / $244.40
| Facility | | $244.40 | $244.40 | $244.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.14 / $289.66 / $565.29
| Professional | | $169.14 | $289.66 | $565.29 |