- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.37 / $189.37 / $218.51
| Professional | | $189.37 | $189.37 | $218.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.86 / $181.86 / $181.86
| Facility | | $181.86 | $181.86 | $181.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.76 / $181.86 / $241.67
| Professional | | $132.76 | $181.86 | $241.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.86 / $181.86 / $181.86
| Facility | | $181.86 | $181.86 | $181.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.76 / $181.86 / $241.67
| Professional | | $132.76 | $181.86 | $241.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.90 / $143.90 / $181.50
| Facility | | $143.90 | $143.90 | $181.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.06 / $229.87 / $448.62
| Professional | | $129.06 | $229.87 | $448.62 |