- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.47 / $183.48 / $315.10
| Professional | | $183.47 | $183.48 | $315.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.71 / $207.71 / $207.71
| Facility | | $207.71 | $207.71 | $207.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $204.02 / $340.03
| Facility | | $173.09 | $204.02 | $340.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $340.03
| Professional | | $183.48 | $183.48 | $340.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.09 / $204.02 / $340.03
| Facility | | $173.09 | $204.02 | $340.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.48 / $183.48 / $340.03
| Professional | | $183.48 | $183.48 | $340.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.38 / $194.49 / $550.44
| Professional | | $157.38 | $194.49 | $550.44 |