- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.23 / $176.23 / $203.34
| Professional | | $176.23 | $176.23 | $203.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.35 / $239.35 / $239.35
| Facility | | $239.35 | $239.35 | $239.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.73 / $174.73 / $174.73
| Professional | | $174.73 | $174.73 | $174.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.35 / $239.35 / $239.35
| Facility | | $239.35 | $239.35 | $239.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.73 / $174.73 / $174.73
| Professional | | $174.73 | $174.73 | $174.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.11 / $248.45 / $417.48
| Professional | | $120.11 | $248.45 | $417.48 |