- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $237.57 / $364.84
| Professional | | $213.84 | $237.57 | $364.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.08 / $242.08 / $242.08
| Facility | | $242.08 | $242.08 | $242.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.74 / $237.63 / $396.05
| Facility | | $201.74 | $237.63 | $396.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $213.84 / $213.84
| Professional | | $213.84 | $213.84 | $213.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.74 / $237.63 / $396.05
| Facility | | $201.74 | $237.63 | $396.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.84 / $213.84 / $213.84
| Professional | | $213.84 | $213.84 | $213.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.15 / $213.84 / $328.95
| Professional | | $203.15 | $213.84 | $328.95 |