- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.68 / $157.68 / $181.94
| Professional | | $157.68 | $157.68 | $181.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.54 / $170.54 / $237.50
| Facility | | $170.54 | $170.54 | $237.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.49 / $170.54 / $175.66
| Professional | | $124.49 | $170.54 | $175.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.54 / $170.54 / $237.50
| Facility | | $170.54 | $170.54 | $237.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.49 / $170.54 / $175.66
| Professional | | $124.49 | $170.54 | $175.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.77 / $191.41 / $373.55
| Professional | | $111.77 | $191.41 | $373.55 |