- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.96 / $186.95 / $246.44
| Professional | | $169.96 | $186.95 | $246.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.50 / $292.50 / $374.61
| Facility | | $292.50 | $292.50 | $374.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.76 / $186.76 / $186.76
| Professional | | $186.76 | $186.76 | $186.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.76 / $186.76 / $186.76
| Professional | | $186.76 | $186.76 | $186.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.41 / $199.95 / $307.58
| Professional | | $158.41 | $199.95 | $307.58 |