- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.07 / $164.07 / $189.31
| Professional | | $164.07 | $164.07 | $189.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.07 / $244.07 / $247.10
| Facility | | $244.07 | $244.07 | $247.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.17 / $244.07 / $251.39
| Professional | | $178.17 | $244.07 | $251.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $244.07 / $244.07 / $247.10
| Facility | | $244.07 | $244.07 | $247.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.17 / $244.07 / $251.39
| Professional | | $178.17 | $244.07 | $251.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.29 / $252.66 / $388.67
| Professional | | $116.29 | $252.66 | $388.67 |