- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.80 / $211.80 / $244.39
| Professional | | $211.80 | $211.80 | $244.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.52 / $299.52 / $319.01
| Facility | | $299.52 | $299.52 | $319.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.65 / $299.52 / $308.51
| Professional | | $218.65 | $299.52 | $308.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.52 / $299.52 / $319.01
| Facility | | $299.52 | $299.52 | $319.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.65 / $299.52 / $308.51
| Professional | | $218.65 | $299.52 | $308.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.13 / $257.11 / $501.77
| Professional | | $150.13 | $257.11 | $501.77 |