- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.35 / $205.35 / $236.94
| Professional | | $205.35 | $205.35 | $236.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.81 / $297.81 / $309.29
| Facility | | $297.81 | $297.81 | $309.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.40 / $283.32 / $306.74
| Professional | | $217.40 | $283.32 | $306.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.81 / $297.81 / $309.29
| Facility | | $297.81 | $297.81 | $309.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.40 / $297.81 / $306.74
| Professional | | $217.40 | $297.81 | $306.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.55 / $269.02 / $486.48
| Professional | | $145.55 | $269.02 | $486.48 |