- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.56 / $185.57 / $185.57
| Professional | | $138.56 | $185.57 | $185.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Facility | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $238.16
| Professional | | $202.44 | $238.16 | $238.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Facility | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Professional | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $200.50 / $274.02
| Professional | | $109.61 | $200.50 | $274.02 |