- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.55 / $170.55 / $196.79
| Professional | | $170.55 | $170.55 | $196.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.51 / $220.51 / $256.87
| Facility | | $220.51 | $220.51 | $256.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.97 / $209.24 / $227.13
| Professional | | $160.97 | $209.24 | $227.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.51 / $220.51 / $256.87
| Facility | | $220.51 | $220.51 | $256.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.97 / $220.51 / $227.13
| Professional | | $160.97 | $220.51 | $227.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.24 / $230.38 / $404.04
| Professional | | $116.24 | $230.38 | $404.04 |