- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.21 / $173.21 / $199.85
| Professional | | $173.21 | $173.21 | $199.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.09 / $205.09 / $260.88
| Facility | | $205.09 | $205.09 | $260.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $205.09 / $218.64
| Professional | | $149.72 | $205.09 | $218.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.09 / $205.09 / $260.88
| Facility | | $205.09 | $205.09 | $260.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $205.09 / $218.64
| Professional | | $149.72 | $205.09 | $218.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.62 / $282.81 / $295.13
| Professional | | $143.62 | $282.81 | $295.13 |