- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.68 / $168.68 / $263.76
| Professional | | $168.68 | $168.68 | $263.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.16 / $294.16 / $294.16
| Facility | | $294.16 | $294.16 | $294.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.16 / $294.16 / $294.16
| Professional | | $294.16 | $294.16 | $294.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.22 / $188.22 / $418.35
| Facility | | $188.22 | $188.22 | $418.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.40 / $137.40 / $188.22
| Professional | | $137.40 | $137.40 | $188.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.82 / $150.28 / $166.84
| Professional | | $135.82 | $150.28 | $166.84 |