- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $165.83 / $278.25
| Professional | | $165.83 | $165.83 | $278.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $187.73 / $187.73 / $187.73
| Facility | | $187.73 | $187.73 | $187.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.44 / $184.94 / $308.24
| Facility | | $156.44 | $184.94 | $308.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $165.83 / $165.83
| Professional | | $165.83 | $165.83 | $165.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.44 / $184.94 / $308.24
| Facility | | $156.44 | $184.94 | $308.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.83 / $165.83 / $165.83
| Professional | | $165.83 | $165.83 | $165.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.54 / $165.83 / $255.10
| Professional | | $157.54 | $165.83 | $255.10 |