- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $269.15
| Professional | | $186.21 | $186.21 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Facility | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Professional | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $165.96 / $181.97
| Professional | | $141.25 | $165.96 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $269.15
| Professional | | $186.21 | $186.21 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $181.97 / $263.03
| Professional | | $151.36 | $181.97 | $263.03 |