- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.45 / $240.45 / $277.45
| Professional | | $240.45 | $240.45 | $277.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $230.92 / $362.16
| Facility | | $230.92 | $230.92 | $362.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.57 / $230.92 / $237.85
| Professional | | $168.57 | $230.92 | $237.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $230.92 / $362.16
| Facility | | $230.92 | $230.92 | $362.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.57 / $230.92 / $237.85
| Professional | | $168.57 | $230.92 | $237.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.88 / $291.88 / $569.64
| Professional | | $163.88 | $291.88 | $569.64 |