- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.17 / $220.17 / $220.17
| Professional | | $220.17 | $220.17 | $220.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.18 / $297.18 / $297.18
| Facility | | $297.18 | $297.18 | $297.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.05 / $205.04 / $255.03
| Professional | | $85.05 | $205.04 | $255.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.18 / $297.18 / $297.18
| Facility | | $297.18 | $297.18 | $297.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.05 / $204.02 / $255.03
| Professional | | $85.05 | $204.02 | $255.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.54 / $106.54 / $248.58
| Professional | | $106.54 | $106.54 | $248.58 |