- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.59 / $216.58 / $216.58
| Professional | | $214.59 | $216.58 | $216.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.78 / $331.78 / $331.78
| Facility | | $331.78 | $331.78 | $331.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.01 / $298.60 / $331.78
| Professional | | $282.01 | $298.60 | $331.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $89.98 / $127.10 / $205.57
| Facility | | $89.98 | $127.10 | $205.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.58 / $224.26 / $376.65
| Professional | | $103.58 | $224.26 | $376.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.39 / $325.75 / $368.67
| Professional | | $273.39 | $325.75 | $368.67 |