- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $229.09
| Professional | | $181.97 | $181.97 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.15 / $165.96 / $295.12
| Facility | | $107.15 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $363.08 / $363.08
| Professional | | $158.49 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $158.49 / $158.49
| Professional | | $158.49 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |