- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.88 / $141.88 / $141.88
| Professional | | $141.88 | $141.88 | $141.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.53 / $191.53 / $191.53
| Facility | | $191.53 | $191.53 | $191.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.75 / $131.75 / $164.68
| Professional | | $131.75 | $131.75 | $164.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $191.53 / $191.53 / $191.53
| Facility | | $191.53 | $191.53 | $191.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.38 / $131.75 / $164.68
| Professional | | $74.38 | $131.75 | $164.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $68.66 / $68.66 / $160.19
| Professional | | $68.66 | $68.66 | $160.19 |