- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.57 / $170.57 / $196.81
| Professional | | $170.57 | $170.57 | $196.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $231.66
| Facility | | $231.66 | $231.66 | $231.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $169.11 / $246.96
| Professional | | $169.11 | $169.11 | $246.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.66 / $231.66 / $231.66
| Facility | | $231.66 | $231.66 | $231.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.11 / $231.66 / $246.96
| Professional | | $169.11 | $231.66 | $246.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.25 / $240.47 / $404.07
| Professional | | $116.25 | $240.47 | $404.07 |