- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.13 / $132.13 / $231.39
| Professional | | $132.13 | $132.13 | $231.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $258.06 / $258.06 / $258.06
| Facility | | $258.06 | $258.06 | $258.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.06 / $258.06 / $258.06
| Professional | | $258.06 | $258.06 | $258.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.22 / $159.22 / $268.75
| Facility | | $159.22 | $159.22 | $268.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.23 / $116.23 / $159.22
| Professional | | $116.23 | $116.23 | $159.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.95 / $148.93 / $172.12
| Professional | | $100.95 | $148.93 | $172.12 |