- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $295.39
| Professional | | $172.22 | $172.22 | $295.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.97 / $194.97 / $194.97
| Facility | | $194.97 | $194.97 | $194.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.47 / $183.91 / $306.52
| Facility | | $162.47 | $183.91 | $306.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.47 / $183.91 / $306.52
| Facility | | $162.47 | $183.91 | $306.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.22 / $172.22 / $172.22
| Professional | | $172.22 | $172.22 | $172.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.61 / $172.22 / $264.93
| Professional | | $163.61 | $172.22 | $264.93 |