- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.70 / $245.70 / $283.50
| Professional | | $245.70 | $245.70 | $283.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.55 / $352.55 / $370.06
| Facility | | $352.55 | $352.55 | $370.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.36 / $352.55 / $363.13
| Professional | | $257.36 | $352.55 | $363.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.55 / $352.55 / $370.06
| Facility | | $352.55 | $352.55 | $370.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.36 / $352.55 / $363.13
| Professional | | $257.36 | $352.55 | $363.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.46 / $298.26 / $582.07
| Professional | | $167.46 | $298.26 | $582.07 |