- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.56 / $214.56 / $214.56
| Professional | | $214.56 | $214.56 | $214.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.61 / $289.61 / $289.61
| Facility | | $289.61 | $289.61 | $289.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.07 / $199.07 / $248.83
| Professional | | $199.07 | $199.07 | $248.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.61 / $289.61 / $289.61
| Facility | | $289.61 | $289.61 | $289.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.47 / $199.07 / $248.83
| Professional | | $112.47 | $199.07 | $248.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.82 / $103.82 / $242.24
| Professional | | $103.82 | $103.82 | $242.24 |