- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.60 / $264.83 / $275.70
| Professional | | $233.60 | $264.83 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.44 / $336.44 / $357.47
| Professional | | $336.44 | $336.44 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $226.63
| Facility | | $226.63 | $226.63 | $226.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $226.63 / $226.63
| Professional | | $192.64 | $226.63 | $226.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.31 / $275.70 / $288.33
| Facility | | $260.31 | $275.70 | $288.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.00 / $1,182.00 / $1,182.00
| Professional | | $1,182.00 | $1,182.00 | $1,182.00 |