- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.77 / $155.77 / $179.74
| Professional | | $155.77 | $155.77 | $179.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.10 / $225.10 / $234.62
| Facility | | $225.10 | $225.10 | $234.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.40 / $200.25 / $231.85
| Professional | | $162.40 | $200.25 | $231.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.10 / $225.10 / $234.62
| Facility | | $225.10 | $225.10 | $234.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.40 / $225.10 / $231.85
| Professional | | $162.40 | $225.10 | $231.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.06 / $172.06 / $172.06
| Facility | | $172.06 | $172.06 | $172.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.41 / $239.89 / $369.03
| Professional | | $110.41 | $239.89 | $369.03 |