- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.97 / $323.18 / $425.95
| Professional | | $214.97 | $323.18 | $425.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $490.48 / $490.48 / $490.48
| Facility | | $490.48 | $490.48 | $490.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $490.48 / $490.48 / $490.48
| Professional | | $490.48 | $490.48 | $490.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.87 / $310.87 / $506.62
| Facility | | $310.87 | $310.87 | $506.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.24 / $310.87 / $416.18
| Professional | | $264.24 | $310.87 | $416.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.69 / $271.45 / $624.49
| Professional | | $153.69 | $271.45 | $624.49 |