- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.65 / $229.60 / $229.60
| Professional | | $191.65 | $229.60 | $229.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.67 / $212.67 / $212.67
| Facility | | $212.67 | $212.67 | $212.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.76 / $193.76 / $212.67
| Professional | | $193.76 | $193.76 | $212.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.67 / $212.67 / $212.67
| Facility | | $212.67 | $212.67 | $212.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.76 / $210.21 / $274.19
| Professional | | $193.76 | $210.21 | $274.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.76 / $193.76 / $193.76
| Professional | | $193.76 | $193.76 | $193.76 |