- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.84 / $166.84 / $292.19
| Professional | | $166.84 | $166.84 | $292.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $325.86 / $325.86 / $325.86
| Facility | | $325.86 | $325.86 | $325.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.86 / $325.86 / $325.86
| Professional | | $325.86 | $325.86 | $325.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.59 / $209.59 / $373.67
| Facility | | $209.59 | $209.59 | $373.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.00 / $153.00 / $209.59
| Professional | | $153.00 | $153.00 | $209.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.70 / $219.98 / $219.98
| Facility | | $125.70 | $219.98 | $219.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.46 / $221.96 / $256.52
| Professional | | $150.46 | $221.96 | $256.52 |