- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.75 / $126.75 / $158.44
| Professional | | $126.75 | $126.75 | $158.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.92 / $165.92 / $209.26
| Facility | | $165.92 | $165.92 | $209.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.66 / $298.66 / $298.66
| Professional | | $298.66 | $298.66 | $298.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.26 / $209.26 / $209.26
| Facility | | $209.26 | $209.26 | $209.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.26 / $231.26 / $298.66
| Professional | | $209.26 | $231.26 | $298.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.43 / $114.43 / $114.43
| Facility | | $114.43 | $114.43 | $114.43 |