- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $162.97 / $188.04
| Professional | | $162.97 | $162.97 | $188.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.68 / $225.68 / $245.45
| Facility | | $225.68 | $225.68 | $245.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.75 / $225.68 / $240.59
| Professional | | $164.75 | $225.68 | $240.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $225.68 / $225.68 / $245.45
| Facility | | $225.68 | $225.68 | $245.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.75 / $225.68 / $240.59
| Professional | | $164.75 | $225.68 | $240.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.52 / $197.83 / $386.07
| Professional | | $115.52 | $197.83 | $386.07 |