- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $263.03 / $467.74
| Professional | | $218.78 | $263.03 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $363.08 / $363.08 / $467.74
| Facility | | $363.08 | $363.08 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $416.87
| Professional | | $263.03 | $263.03 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.49 / $275.42 / $363.08
| Facility | | $158.49 | $275.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $208.93 / $323.59
| Professional | | $190.55 | $208.93 | $323.59 |