- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.29 / $197.29 / $227.64
| Professional | | $197.29 | $197.29 | $227.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.94 / $267.94 / $267.94
| Facility | | $267.94 | $267.94 | $267.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.60 / $195.60 / $285.63
| Professional | | $195.60 | $195.60 | $285.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.94 / $267.94 / $267.94
| Facility | | $267.94 | $267.94 | $267.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.60 / $267.94 / $285.63
| Professional | | $195.60 | $267.94 | $285.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.46 / $278.14 / $467.37
| Professional | | $134.46 | $278.14 | $467.37 |