- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.38 / $219.38 / $253.13
| Professional | | $219.38 | $219.38 | $253.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.41 / $335.84 / $335.84
| Facility | | $330.41 | $335.84 | $335.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.16 / $245.16 / $277.23
| Professional | | $245.16 | $245.16 | $277.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.41 / $335.84 / $335.84
| Facility | | $330.41 | $335.84 | $335.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.16 / $245.16 / $277.23
| Professional | | $245.16 | $245.16 | $277.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.49 / $266.30 / $519.70
| Professional | | $155.49 | $266.30 | $519.70 |