- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.02 / $278.02 / $320.79
| Professional | | $278.02 | $278.02 | $320.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.77 / $271.77 / $418.74
| Facility | | $271.77 | $271.77 | $418.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.39 / $271.77 / $289.72
| Professional | | $198.39 | $271.77 | $289.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.77 / $271.77 / $418.74
| Facility | | $271.77 | $271.77 | $418.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.39 / $271.77 / $289.72
| Professional | | $198.39 | $271.77 | $289.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.49 / $337.48 / $658.63
| Professional | | $189.49 | $337.48 | $658.63 |