- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.85 / $118.85 / $185.84
| Professional | | $118.85 | $118.85 | $185.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.26 / $207.26 / $207.26
| Facility | | $207.26 | $207.26 | $207.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.26 / $207.26 / $207.26
| Professional | | $207.26 | $207.26 | $207.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.11 / $149.11 / $229.83
| Facility | | $149.11 | $149.11 | $229.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.85 / $108.85 / $149.11
| Professional | | $108.85 | $108.85 | $149.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.56 / $93.57 / $103.88
| Professional | | $84.56 | $93.57 | $103.88 |