- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.27 / $138.27 / $159.55
| Professional | | $138.27 | $138.27 | $159.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.64 / $177.64 / $208.26
| Facility | | $177.64 | $177.64 | $208.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.68 / $177.64 / $189.38
| Professional | | $129.68 | $177.64 | $189.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.64 / $177.64 / $208.26
| Facility | | $177.64 | $177.64 | $208.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.68 / $177.64 / $189.38
| Professional | | $129.68 | $177.64 | $189.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.01 / $175.31 / $327.57
| Professional | | $98.01 | $175.31 | $327.57 |