- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.08 / $161.44 / $182.97
| Professional | | $156.08 | $161.44 | $182.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.83 / $302.83 / $302.83
| Facility | | $302.83 | $302.83 | $302.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.41 / $257.41 / $302.83
| Professional | | $257.41 | $257.41 | $302.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.27 / $224.66 / $224.66
| Facility | | $0.27 | $224.66 | $224.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $176.71 / $209.70 / $294.81
| Professional | | $176.71 | $209.70 | $294.81 |