- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.90 / $244.90 / $260.20
| Professional | | $244.90 | $244.90 | $260.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.20 / $270.41 / $285.70
| Facility | | $260.20 | $270.41 | $285.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.51 / $275.51 / $275.51
| Professional | | $275.51 | $275.51 | $275.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Facility | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.20 / $260.20 / $260.20
| Professional | | $260.20 | $260.20 | $260.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.10 / $255.10 / $255.10
| Professional | | $255.10 | $255.10 | $255.10 |