- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.20 / $216.20 / $249.46
| Professional | | $216.20 | $216.20 | $249.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.67 / $280.67 / $325.62
| Facility | | $280.67 | $280.67 | $325.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.89 / $280.67 / $289.08
| Professional | | $204.89 | $280.67 | $289.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $280.67 / $280.67 / $325.62
| Facility | | $280.67 | $280.67 | $325.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.89 / $280.67 / $289.08
| Professional | | $204.89 | $280.67 | $289.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.34 / $262.44 / $512.16
| Professional | | $147.34 | $262.44 | $512.16 |