- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.53 / $283.30 / $283.30
| Professional | | $211.53 | $283.30 | $283.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $292.50
| Facility | | $292.50 | $292.50 | $292.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.63 / $292.50 / $301.27
| Professional | | $248.63 | $292.50 | $301.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $292.50
| Facility | | $292.50 | $292.50 | $292.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $301.27
| Professional | | $292.50 | $292.50 | $301.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.34 / $306.08 / $418.36
| Professional | | $167.34 | $306.08 | $418.36 |