- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.43 / $285.43 / $329.35
| Professional | | $285.43 | $285.43 | $329.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.42 / $340.42 / $429.90
| Facility | | $340.42 | $340.42 | $429.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.51 / $340.42 / $350.63
| Professional | | $248.51 | $340.42 | $350.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.42 / $340.42 / $429.90
| Facility | | $340.42 | $340.42 | $429.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.51 / $340.42 / $350.63
| Professional | | $248.51 | $340.42 | $350.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.54 / $377.36 / $676.19
| Professional | | $194.54 | $377.36 | $676.19 |