- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.05 / $126.05 / $156.79
| Professional | | $126.05 | $126.05 | $156.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.85 / $195.78 / $195.78
| Facility | | $189.85 | $195.78 | $195.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.97 / $166.41 / $166.41
| Professional | | $147.97 | $166.41 | $166.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.85 / $195.78 / $195.78
| Facility | | $189.85 | $195.78 | $195.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.97 / $166.41 / $422.25
| Professional | | $147.97 | $166.41 | $422.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.91 / $178.39 / $298.60
| Professional | | $85.91 | $178.39 | $298.60 |