- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.58 / $221.58 / $233.12
| Professional | | $221.58 | $221.58 | $233.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.46 / $308.62 / $308.62
| Professional | | $231.46 | $308.62 | $308.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.47 / $297.47 / $297.47
| Facility | | $297.47 | $297.47 | $297.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.98 / $254.98 / $265.60
| Professional | | $254.98 | $254.98 | $265.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.38 / $165.38 / $356.52
| Professional | | $165.38 | $165.38 | $356.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.24 / $354.52 / $483.28
| Professional | | $293.24 | $354.52 | $483.28 |