- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.81 / $168.81 / $194.78
| Professional | | $168.81 | $168.81 | $194.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.51 / $203.51 / $254.24
| Facility | | $203.51 | $203.51 | $254.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.56 / $203.51 / $216.96
| Professional | | $148.56 | $203.51 | $216.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $203.51 / $203.51 / $254.24
| Facility | | $203.51 | $203.51 | $254.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.56 / $203.51 / $216.96
| Professional | | $148.56 | $203.51 | $216.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.05 / $244.81 / $399.90
| Professional | | $115.05 | $244.81 | $399.90 |