- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.27 / $168.27 / $194.15
| Professional | | $168.27 | $168.27 | $194.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.43 / $265.56 / $265.56
| Facility | | $253.43 | $265.56 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.70 / $218.85 / $283.10
| Professional | | $191.70 | $218.85 | $283.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.43 / $265.56 / $265.56
| Facility | | $253.43 | $265.56 | $265.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.70 / $265.56 / $283.10
| Professional | | $191.70 | $265.56 | $283.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.68 / $231.43 / $398.62
| Professional | | $114.68 | $231.43 | $398.62 |