- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.37 / $109.37 / $126.20
| Professional | | $109.37 | $109.37 | $126.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.22 / $159.22 / $164.73
| Facility | | $159.22 | $159.22 | $164.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.23 / $159.22 / $169.73
| Professional | | $116.23 | $159.22 | $169.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.22 / $159.22 / $164.73
| Facility | | $159.22 | $159.22 | $164.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.23 / $159.22 / $169.73
| Professional | | $116.23 | $159.22 | $169.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.54 / $168.29 / $259.10
| Professional | | $74.54 | $168.29 | $259.10 |