- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.70 / $165.70 / $191.19
| Professional | | $165.70 | $165.70 | $191.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.30 / $225.30 / $249.57
| Facility | | $225.30 | $225.30 | $249.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.47 / $225.30 / $232.06
| Professional | | $164.47 | $225.30 | $232.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.30 / $225.30 / $249.57
| Facility | | $225.30 | $225.30 | $249.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.47 / $225.30 / $232.06
| Professional | | $164.47 | $225.30 | $232.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.94 / $201.14 / $392.55
| Professional | | $112.94 | $201.14 | $392.55 |