- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.49 / $343.49 / $343.49
| Professional | | $343.49 | $343.49 | $343.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.66 / $502.66 / $502.66
| Facility | | $502.66 | $502.66 | $502.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.66 / $502.66 / $502.66
| Professional | | $502.66 | $502.66 | $502.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $502.66 / $502.66 / $502.66
| Facility | | $502.66 | $502.66 | $502.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.66 / $601.13 / $707.25
| Professional | | $502.66 | $601.13 | $707.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.55 / $564.04 / $884.29
| Professional | | $487.55 | $564.04 | $884.29 |