- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $352.67
| Professional | | $204.61 | $204.61 | $352.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.64 / $231.64 / $231.64
| Facility | | $231.64 | $231.64 | $231.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.03 / $204.61 / $387.24
| Facility | | $193.03 | $204.61 | $387.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Professional | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.03 / $204.61 / $387.24
| Facility | | $193.03 | $204.61 | $387.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.61 / $204.61 / $204.61
| Professional | | $204.61 | $204.61 | $204.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.38 / $204.61 / $212.79
| Professional | | $194.38 | $204.61 | $212.79 |