- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.53 / $194.53 / $304.18
| Professional | | $194.53 | $194.53 | $304.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.24 / $339.24 / $339.24
| Facility | | $339.24 | $339.24 | $339.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.24 / $339.24 / $339.24
| Professional | | $339.24 | $339.24 | $339.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $376.08
| Facility | | $192.25 | $192.25 | $376.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.34 / $140.34 / $192.25
| Professional | | $140.34 | $140.34 | $192.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.72 / $153.49 / $170.40
| Professional | | $138.72 | $153.49 | $170.40 |