- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $296.44
| Professional | | $173.03 | $173.03 | $296.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.88 / $195.88 / $195.88
| Facility | | $195.88 | $195.88 | $195.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.24 / $186.71 / $311.18
| Facility | | $163.24 | $186.71 | $311.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $311.18
| Professional | | $173.03 | $173.03 | $311.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $163.24 / $186.71 / $311.18
| Facility | | $163.24 | $186.71 | $311.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $173.03 / $311.18
| Professional | | $173.03 | $173.03 | $311.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.03 / $183.41 / $400.44
| Professional | | $173.03 | $183.41 | $400.44 |