- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $191.91 / $191.92 / $191.92
| Professional | | $191.91 | $191.92 | $191.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.54 / $161.54 / $161.54
| Facility | | $161.54 | $161.54 | $161.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.54 / $161.54 / $161.54
| Professional | | $161.54 | $161.54 | $161.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.55 / $188.55 / $188.55
| Facility | | $188.55 | $188.55 | $188.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.55 / $188.55 / $188.55
| Professional | | $188.55 | $188.55 | $188.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.35 / $168.35 / $202.02
| Professional | | $168.35 | $168.35 | $202.02 |