- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.74 / $211.74 / $244.32
| Professional | | $211.74 | $211.74 | $244.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.80 / $286.80 / $286.80
| Facility | | $286.80 | $286.80 | $286.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.36 / $209.36 / $209.36
| Professional | | $209.36 | $209.36 | $209.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $286.80 / $286.80 / $286.80
| Facility | | $286.80 | $286.80 | $286.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.36 / $209.36 / $209.36
| Professional | | $209.36 | $209.36 | $209.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.46 / $326.08 / $501.63
| Professional | | $195.46 | $326.08 | $501.63 |