- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.91 / $216.92 / $216.92
| Professional | | $216.91 | $216.92 | $216.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.19 / $238.19 / $238.19
| Facility | | $238.19 | $238.19 | $238.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.19 / $238.19 / $238.19
| Professional | | $238.19 | $238.19 | $238.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $216.92 / $229.94 / $310.20
| Facility | | $216.92 | $229.94 | $310.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.53 / $262.86 / $350.48
| Professional | | $247.53 | $262.86 | $350.48 |