- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.09 / $218.28 / $326.11
| Professional | | $184.09 | $218.28 | $326.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.17 / $440.17 / $440.17
| Facility | | $440.17 | $440.17 | $440.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.29 / $307.42 / $611.40
| Professional | | $129.29 | $307.42 | $611.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.17 / $440.17 / $440.17
| Facility | | $440.17 | $440.17 | $440.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.29 / $307.42 / $611.40
| Professional | | $129.29 | $307.42 | $611.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.87 / $368.19 / $607.61
| Professional | | $114.87 | $368.19 | $607.61 |