- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.83 / $147.83 / $147.83
| Professional | | $147.83 | $147.83 | $147.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.41 / $177.41 / $177.41
| Facility | | $177.41 | $177.41 | $177.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.27 / $274.27 / $274.27
| Professional | | $274.27 | $274.27 | $274.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.35 / $19.35 / $19.35
| Professional | | $19.35 | $19.35 | $19.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.52 / $177.41 / $256.62
| Professional | | $169.52 | $177.41 | $256.62 |