- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $354.81 / $371.54
| Professional | | $114.82 | $354.81 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $125.89 / $354.81
| Professional | | $125.89 | $125.89 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Professional | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $363.08
| Professional | | $354.81 | $354.81 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $354.81 / $457.09
| Professional | | $117.49 | $354.81 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $354.81 / $478.63
| Professional | | $125.89 | $354.81 | $478.63 |