- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.26 / $136.26 / $238.63
| Professional | | $136.26 | $136.26 | $238.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.13 / $266.13 / $266.13
| Facility | | $266.13 | $266.13 | $266.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.13 / $266.13 / $266.13
| Professional | | $266.13 | $266.13 | $266.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $184.91 / $184.91 / $276.83
| Facility | | $184.91 | $184.91 | $276.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.97 / $134.97 / $184.91
| Professional | | $134.97 | $134.97 | $184.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.91 / $162.13 / $187.40
| Professional | | $109.91 | $162.13 | $187.40 |