- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.10 / $263.10 / $303.58
| Professional | | $263.10 | $263.10 | $303.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.68 / $252.68 / $396.28
| Facility | | $252.68 | $252.68 | $396.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $194.10 / $260.26
| Professional | | $194.10 | $194.10 | $260.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.68 / $252.68 / $396.28
| Facility | | $252.68 | $252.68 | $396.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $251.76 / $260.26
| Professional | | $194.10 | $251.76 | $260.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.32 / $319.38 / $623.29
| Professional | | $179.32 | $319.38 | $623.29 |