- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.39 / $299.39 / $302.62
| Professional | | $299.39 | $299.39 | $302.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.64 / $216.64 / $259.56
| Professional | | $216.64 | $216.64 | $259.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.22 / $161.61 / $161.61
| Facility | | $158.22 | $161.61 | $161.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.61 / $161.61 / $161.61
| Professional | | $161.61 | $161.61 | $161.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.57 / $712.44 / $712.44
| Facility | | $378.57 | $712.44 | $712.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,080.20 / $1,080.20 / $1,080.20
| Professional | | $1,080.20 | $1,080.20 | $1,080.20 |