- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.96 / $565.13 / $565.13
| Professional | | $421.96 | $565.13 | $565.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.74 / $255.74 / $255.74
| Facility | | $255.74 | $255.74 | $255.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.38 / $255.74 / $263.41
| Professional | | $217.38 | $255.74 | $263.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.74 / $255.74 / $255.74
| Facility | | $255.74 | $255.74 | $255.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.74 / $255.74 / $263.41
| Professional | | $255.74 | $255.74 | $263.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.28 / $528.21 / $558.17
| Professional | | $211.28 | $528.21 | $558.17 |