- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.02 / $164.02 / $164.02
| Professional | | $164.02 | $164.02 | $164.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.81 / $206.81 / $206.81
| Facility | | $206.81 | $206.81 | $206.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.81 / $206.81 / $206.81
| Professional | | $206.81 | $206.81 | $206.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.81 / $206.81 / $206.81
| Facility | | $206.81 | $206.81 | $206.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.37 / $128.37 / $206.81
| Professional | | $128.37 | $128.37 | $206.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.90 / $59.90 / $142.63
| Professional | | $59.90 | $59.90 | $142.63 |