- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $249.42
| Professional | | $207.13 | $207.13 | $249.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.48 / $234.48 / $234.48
| Facility | | $234.48 | $234.48 | $234.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.63 / $212.63 / $212.63
| Professional | | $212.63 | $212.63 | $212.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.40 / $232.12 / $386.86
| Facility | | $195.40 | $232.12 | $386.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $386.86
| Professional | | $207.13 | $207.13 | $386.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.40 / $232.12 / $386.86
| Facility | | $195.40 | $232.12 | $386.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.13 / $207.13 / $386.86
| Professional | | $207.13 | $207.13 | $386.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.80 / $219.56 / $621.39
| Professional | | $170.80 | $219.56 | $621.39 |