- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.03 / $165.03 / $190.42
| Professional | | $165.03 | $165.03 | $190.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.91 / $159.91 / $248.56
| Facility | | $159.91 | $159.91 | $248.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.74 / $116.74 / $159.51
| Professional | | $116.74 | $116.74 | $159.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.91 / $159.91 / $248.56
| Facility | | $159.91 | $159.91 | $248.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.74 / $116.74 / $159.51
| Professional | | $116.74 | $116.74 | $159.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.48 / $200.33 / $390.95
| Professional | | $112.48 | $200.33 | $390.95 |