- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.19 / $286.87 / $286.87
| Professional | | $214.19 | $286.87 | $286.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.53 / $331.53 / $331.53
| Facility | | $331.53 | $331.53 | $331.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.80 / $331.53 / $341.48
| Professional | | $281.80 | $331.53 | $341.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.53 / $331.53 / $331.53
| Facility | | $331.53 | $331.53 | $331.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.53 / $331.53 / $341.48
| Professional | | $331.53 | $331.53 | $341.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.72 / $331.70 / $443.77
| Professional | | $158.72 | $331.70 | $443.77 |