- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.73 / $278.42 / $372.89
| Professional | | $186.73 | $278.42 | $372.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.55 / $353.55 / $464.03
| Facility | | $353.55 | $353.55 | $464.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.52 / $353.55 / $464.03
| Professional | | $300.52 | $353.55 | $464.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.55 / $353.55 / $464.03
| Facility | | $353.55 | $353.55 | $464.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.55 / $353.55 / $464.03
| Professional | | $353.55 | $353.55 | $464.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.98 / $497.68 / $550.63
| Professional | | $178.98 | $497.68 | $550.63 |