- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.28 / $141.28 / $163.01
| Professional | | $141.28 | $141.28 | $163.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.96 / $169.96 / $212.78
| Facility | | $169.96 | $169.96 | $212.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.07 / $124.07 / $139.33
| Professional | | $124.07 | $124.07 | $139.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $169.96 / $169.96 / $212.78
| Facility | | $169.96 | $169.96 | $212.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.07 / $124.07 / $139.33
| Professional | | $124.07 | $124.07 | $139.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.65 / $240.72 / $240.72
| Professional | | $111.65 | $240.72 | $240.72 |