- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.79 / $164.79 / $288.58
| Professional | | $164.79 | $164.79 | $288.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.83 / $321.83 / $321.83
| Professional | | $321.83 | $321.83 | $321.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $426.50
| Facility | | $238.16 | $238.16 | $426.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $238.16
| Professional | | $238.16 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.35 / $164.42 / $247.67
| Professional | | $139.35 | $164.42 | $247.67 |