- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.98 / $182.98 / $211.13
| Professional | | $182.98 | $182.98 | $211.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.07 / $227.07 / $275.58
| Facility | | $227.07 | $227.07 | $275.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.76 / $227.07 / $242.07
| Professional | | $165.76 | $227.07 | $242.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $227.07 / $227.07 / $275.58
| Facility | | $227.07 | $227.07 | $275.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.76 / $227.07 / $242.07
| Professional | | $165.76 | $227.07 | $242.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.72 / $222.11 / $433.46
| Professional | | $124.72 | $222.11 | $433.46 |