- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.97 / $186.97 / $215.74
| Professional | | $186.97 | $186.97 | $215.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.61 / $305.27 / $305.27
| Facility | | $281.61 | $305.27 | $305.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.85 / $264.73 / $314.44
| Professional | | $222.85 | $264.73 | $314.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $281.61 / $305.27 / $305.27
| Facility | | $281.61 | $305.27 | $305.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.85 / $305.27 / $314.44
| Professional | | $222.85 | $305.27 | $314.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.59 / $305.29 / $318.58
| Professional | | $172.59 | $305.29 | $318.58 |