- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.87 / $87.87 / $109.09
| Professional | | $87.87 | $87.87 | $109.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.62 / $124.62 / $124.62
| Facility | | $124.62 | $124.62 | $124.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.62 / $124.62 / $134.63
| Professional | | $124.62 | $124.62 | $134.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.49 / $375.56 / $427.30
| Professional | | $227.49 | $375.56 | $427.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.27 / $325.33 / $427.30
| Professional | | $265.27 | $325.33 | $427.30 |