- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.64 / $263.64 / $304.22
| Professional | | $263.64 | $263.64 | $304.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.20 / $253.20 / $397.10
| Facility | | $253.20 | $253.20 | $397.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $253.20 / $260.80
| Professional | | $184.84 | $253.20 | $260.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.20 / $253.20 / $397.10
| Facility | | $253.20 | $253.20 | $397.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.84 / $253.20 / $260.80
| Professional | | $184.84 | $253.20 | $260.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.70 / $320.05 / $624.60
| Professional | | $179.70 | $320.05 | $624.60 |