- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.05 / $213.05 / $245.83
| Professional | | $213.05 | $213.05 | $245.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.35 / $318.35 / $318.35
| Facility | | $318.35 | $318.35 | $318.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.40 / $232.40 / $339.37
| Professional | | $232.40 | $232.40 | $339.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.35 / $318.35 / $318.35
| Facility | | $318.35 | $318.35 | $318.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.40 / $318.35 / $339.37
| Professional | | $232.40 | $318.35 | $339.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.66 / $328.10 / $504.72
| Professional | | $196.66 | $328.10 | $504.72 |