- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.85 / $141.85 / $170.86
| Professional | | $141.85 | $141.85 | $170.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.68 / $210.68 / $210.68
| Facility | | $210.68 | $210.68 | $210.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.80 / $210.68 / $333.92
| Professional | | $153.80 | $210.68 | $333.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.68 / $210.68 / $210.68
| Facility | | $210.68 | $210.68 | $210.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.80 / $210.68 / $333.92
| Professional | | $153.80 | $210.68 | $333.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.89 / $220.29 / $370.86
| Professional | | $95.89 | $220.29 | $370.86 |