- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.13 / $141.13 / $162.84
| Professional | | $141.13 | $141.13 | $162.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.71 / $180.71 / $212.56
| Facility | | $180.71 | $180.71 | $212.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $180.71 / $192.64
| Professional | | $131.91 | $180.71 | $192.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.71 / $180.71 / $212.56
| Facility | | $180.71 | $180.71 | $212.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.91 / $180.71 / $192.64
| Professional | | $131.91 | $180.71 | $192.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.27 / $217.34 / $334.34
| Professional | | $130.27 | $217.34 | $334.34 |