- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.50 / $146.50 / $169.04
| Professional | | $146.50 | $146.50 | $169.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.40 / $165.40 / $220.65
| Facility | | $165.40 | $165.40 | $220.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.74 / $165.40 / $176.33
| Professional | | $120.74 | $165.40 | $176.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.40 / $165.40 / $220.65
| Facility | | $165.40 | $165.40 | $220.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.74 / $165.40 / $176.33
| Professional | | $120.74 | $165.40 | $176.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.84 / $177.84 / $347.06
| Professional | | $103.84 | $177.84 | $347.06 |