- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.98 / $272.27 / $381.08
| Professional | | $198.98 | $272.27 | $381.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.81 / $382.81 / $382.81
| Facility | | $382.81 | $382.81 | $382.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.39 / $382.81 / $394.29
| Professional | | $325.39 | $382.81 | $394.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.81 / $382.81 / $382.81
| Facility | | $382.81 | $382.81 | $382.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $382.81 / $382.81 / $394.29
| Professional | | $382.81 | $382.81 | $394.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.51 / $332.78 / $378.23
| Professional | | $145.51 | $332.78 | $378.23 |