- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.58 / $220.43 / $220.43
| Professional | | $164.58 | $220.43 | $220.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.43 / $240.50 / $240.50
| Professional | | $204.43 | $240.50 | $240.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Professional | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.74 / $210.53 / $276.83
| Professional | | $110.74 | $210.53 | $276.83 |