- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $188.95 / $196.09
| Professional | | $162.97 | $188.95 | $196.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $503.92 / $503.92 / $503.92
| Facility | | $503.92 | $503.92 | $503.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.28 / $173.28 / $173.28
| Professional | | $173.28 | $173.28 | $173.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.27 / $203.81 / $203.81
| Facility | | $190.27 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.81 / $203.81 / $203.81
| Professional | | $203.81 | $203.81 | $203.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $188.57 / $289.27
| Professional | | $162.97 | $188.57 | $289.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $188.95 / $196.09
| Professional | | $162.97 | $188.95 | $196.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.97 / $164.26 / $285.22
| Professional | | $162.97 | $164.26 | $285.22 |