- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.96 / $195.96 / $226.10
| Professional | | $195.96 | $195.96 | $226.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.19 / $188.19 / $295.14
| Facility | | $188.19 | $188.19 | $295.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.38 / $188.19 / $200.62
| Professional | | $137.38 | $188.19 | $200.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $188.19 / $188.19 / $295.14
| Facility | | $188.19 | $188.19 | $295.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.38 / $188.19 / $200.62
| Professional | | $137.38 | $188.19 | $200.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.56 / $214.65 / $464.22
| Professional | | $133.56 | $214.65 | $464.22 |