- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $204.96
| Professional | | $204.96 | $204.96 | $204.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.35 / $297.66 / $496.09
| Facility | | $193.35 | $297.66 | $496.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $496.09
| Professional | | $204.96 | $204.96 | $496.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.35 / $297.66 / $496.09
| Facility | | $193.35 | $297.66 | $496.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $496.09
| Professional | | $204.96 | $204.96 | $496.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $614.88
| Professional | | $204.96 | $204.96 | $614.88 |