- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.65 / $660.30 / $660.30
| Professional | | $129.65 | $660.30 | $660.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.12 / $196.12 / $196.12
| Facility | | $196.12 | $196.12 | $196.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.96 / $196.12 / $211.27
| Professional | | $146.96 | $196.12 | $211.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $96.88 / $257.39 / $280.20
| Facility | | $96.88 | $257.39 | $280.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.75 / $176.65 / $254.80
| Professional | | $117.75 | $176.65 | $254.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.77 / $217.81 / $338.56
| Professional | | $188.77 | $217.81 | $338.56 |