- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $253.36 / $253.36
| Professional | | $238.46 | $253.36 | $253.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.36 / $298.07 / $298.07
| Facility | | $253.36 | $298.07 | $298.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $298.07 / $298.07
| Professional | | $253.36 | $298.07 | $298.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.36 / $253.36 / $253.36
| Professional | | $253.36 | $253.36 | $253.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.39 / $248.39 / $248.39
| Professional | | $248.39 | $248.39 | $248.39 |