- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $188.95
| Professional | | $162.97 | $162.97 | $188.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $153.75 / $203.81
| Facility | | $153.75 | $153.75 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.97 / $172.76 / $233.06
| Facility | | $162.97 | $172.76 | $233.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.94 / $179.28 / $203.73
| Professional | | $134.94 | $179.28 | $203.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.20 / $233.20 / $238.50
| Professional | | $233.20 | $233.20 | $238.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.17 / $195.58 / $228.17
| Professional | | $184.17 | $195.58 | $228.17 |