- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.55 / $177.55 / $277.62
| Professional | | $177.55 | $177.55 | $277.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.62 / $309.62 / $309.62
| Facility | | $309.62 | $309.62 | $309.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.62 / $309.62 / $309.62
| Professional | | $309.62 | $309.62 | $309.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.09 / $205.09 / $396.59
| Facility | | $205.09 | $205.09 | $396.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.72 / $149.72 / $205.09
| Professional | | $149.72 | $149.72 | $205.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.96 / $158.16 / $175.60
| Professional | | $142.96 | $158.16 | $175.60 |