- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.35 / $170.61 / $296.69
| Professional | | $154.35 | $170.61 | $296.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.88 / $155.88 / $334.28
| Facility | | $155.88 | $155.88 | $334.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $155.88
| Professional | | $141.60 | $141.60 | $155.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.88 / $155.88 / $334.28
| Facility | | $155.88 | $155.88 | $334.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $153.63 / $200.39
| Professional | | $141.60 | $153.63 | $200.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.60 / $141.60 / $141.60
| Professional | | $141.60 | $141.60 | $141.60 |