- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $180.86 / $238.41
| Professional | | $164.42 | $180.86 | $238.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.69 / $207.69 / $372.11
| Facility | | $207.69 | $207.69 | $372.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.69 / $207.69 / $342.28
| Facility | | $207.69 | $207.69 | $342.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Professional | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.69 / $207.69 / $342.28
| Facility | | $207.69 | $207.69 | $342.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.62 / $219.62 / $219.62
| Professional | | $219.62 | $219.62 | $219.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.42 / $235.16 / $235.16
| Professional | | $164.42 | $235.16 | $235.16 |