- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.03 / $181.03 / $317.02
| Professional | | $181.03 | $181.03 | $317.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.56 / $353.56 / $353.56
| Facility | | $353.56 | $353.56 | $353.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.56 / $353.56 / $353.56
| Professional | | $353.56 | $353.56 | $353.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $391.93
| Facility | | $231.66 | $231.66 | $391.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $169.11 / $231.66
| Professional | | $169.11 | $169.11 | $231.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.25 / $212.81 / $245.94
| Professional | | $144.25 | $212.81 | $245.94 |