- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.30 / $166.30 / $191.88
| Professional | | $166.30 | $166.30 | $191.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.47 / $302.83 / $302.83
| Facility | | $250.47 | $302.83 | $302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.36 / $257.41 / $311.93
| Professional | | $212.36 | $257.41 | $311.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $250.47 / $302.83 / $302.83
| Facility | | $250.47 | $302.83 | $302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.36 / $302.83 / $311.93
| Professional | | $212.36 | $302.83 | $311.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.66 / $224.66 / $269.18
| Facility | | $224.66 | $224.66 | $269.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.34 / $256.10 / $393.96
| Professional | | $113.34 | $256.10 | $393.96 |