- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $226.43
| Professional | | $162.97 | $162.97 | $226.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.50 / $184.50 / $184.50
| Facility | | $184.50 | $184.50 | $184.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.75 / $198.27 / $249.94
| Facility | | $153.75 | $198.27 | $249.94 |
- 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
- $153.75 / $198.27 / $249.94
| Facility | | $153.75 | $198.27 | $249.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.83 / $218.36 / $335.91
| Professional | | $154.83 | $218.36 | $335.91 |