- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.39 / $120.39 / $210.84
| Professional | | $120.39 | $120.39 | $210.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.14 / $235.14 / $235.14
| Facility | | $235.14 | $235.14 | $235.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.14 / $235.14 / $235.14
| Professional | | $235.14 | $235.14 | $235.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.64 / $170.64 / $314.52
| Facility | | $170.64 | $170.64 | $314.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.57 / $124.57 / $170.64
| Professional | | $124.57 | $124.57 | $170.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.57 / $122.78 / $215.96
| Professional | | $108.57 | $122.78 | $215.96 |