- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.65 / $163.65 / $188.83
| Professional | | $163.65 | $163.65 | $188.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $192.25 / $198.02
| Professional | | $140.34 | $192.25 | $198.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $192.25
| Facility | | $192.25 | $192.25 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $192.25 / $198.02
| Professional | | $140.34 | $192.25 | $198.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.54 / $214.22 / $387.68
| Professional | | $111.54 | $214.22 | $387.68 |