- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.47 / $136.47 / $238.99
| Professional | | $136.47 | $136.47 | $238.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $266.54 / $266.54 / $266.54
| Facility | | $266.54 | $266.54 | $266.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.54 / $266.54 / $266.54
| Professional | | $266.54 | $266.54 | $266.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.54 / $170.54 / $301.48
| Facility | | $170.54 | $170.54 | $301.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.49 / $124.49 / $170.54
| Professional | | $124.49 | $124.49 | $170.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.07 / $181.54 / $209.82
| Professional | | $123.07 | $181.54 | $209.82 |