- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $239.16
| Professional | | $197.83 | $197.83 | $239.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.96 / $223.96 / $223.96
| Facility | | $223.96 | $223.96 | $223.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.63 / $219.71 / $366.18
| Facility | | $186.63 | $219.71 | $366.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $366.18
| Professional | | $197.83 | $197.83 | $366.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.63 / $219.71 / $366.18
| Facility | | $186.63 | $219.71 | $366.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.83 / $197.83 / $366.18
| Professional | | $197.83 | $197.83 | $366.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.63 / $209.70 / $457.07
| Professional | | $196.63 | $209.70 | $457.07 |