- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.35 / $238.35 / $275.02
| Professional | | $238.35 | $238.35 | $275.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.90 / $228.90 / $358.99
| Facility | | $228.90 | $228.90 | $358.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.57 / $228.22 / $235.77
| Professional | | $194.57 | $228.22 | $235.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $228.90 / $228.90 / $358.99
| Facility | | $228.90 | $228.90 | $358.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.57 / $228.90 / $235.77
| Professional | | $194.57 | $228.90 | $235.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.75 / $367.06 / $564.65
| Professional | | $182.75 | $367.06 | $564.65 |