- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.68 / $188.68 / $217.71
| Professional | | $188.68 | $188.68 | $217.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.17 / $292.48 / $292.48
| Facility | | $284.17 | $292.48 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.51 / $292.48 / $301.25
| Professional | | $213.51 | $292.48 | $301.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $284.17 / $292.48 / $292.48
| Facility | | $284.17 | $292.48 | $292.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.51 / $292.48 / $301.25
| Professional | | $213.51 | $292.48 | $301.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.60 / $273.55 / $446.99
| Professional | | $128.60 | $273.55 | $446.99 |