- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.29 / $145.29 / $167.64
| Professional | | $145.29 | $145.29 | $167.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.29 / $170.29 / $218.83
| Facility | | $170.29 | $170.29 | $218.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.75 / $169.60 / $175.40
| Professional | | $144.75 | $169.60 | $175.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.29 / $170.29 / $218.83
| Facility | | $170.29 | $170.29 | $218.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.75 / $170.29 / $175.40
| Professional | | $144.75 | $170.29 | $175.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.02 / $176.37 / $344.18
| Professional | | $99.02 | $176.37 | $344.18 |