- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.63 / $219.63 / $253.42
| Professional | | $219.63 | $219.63 | $253.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.68 / $271.68 / $330.79
| Facility | | $271.68 | $271.68 | $330.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $266.89 / $289.63
| Professional | | $198.33 | $266.89 | $289.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.68 / $271.68 / $330.79
| Facility | | $271.68 | $271.68 | $330.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.33 / $271.68 / $289.63
| Professional | | $198.33 | $271.68 | $289.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.69 / $266.60 / $520.29
| Professional | | $149.69 | $266.60 | $520.29 |