- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.56 / $266.56 / $307.57
| Professional | | $266.56 | $266.56 | $307.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.03 / $362.03 / $401.48
| Facility | | $362.03 | $362.03 | $401.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.27 / $311.33 / $385.94
| Professional | | $264.27 | $311.33 | $385.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.03 / $362.03 / $401.48
| Facility | | $362.03 | $362.03 | $401.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.27 / $362.03 / $385.94
| Professional | | $264.27 | $362.03 | $385.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.67 / $375.80 / $631.48
| Professional | | $181.67 | $375.80 | $631.48 |