- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.50 / $209.50 / $1,400.01
| Professional | | $209.50 | $209.50 | $1,400.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.44 / $299.44 / $400.87
| Facility | | $299.44 | $299.44 | $400.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.52 / $299.44 / $526.88
| Professional | | $254.52 | $299.44 | $526.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.70 / $303.61 / $437.60
| Professional | | $208.70 | $303.61 | $437.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.28 / $235.28 / $317.95
| Professional | | $235.28 | $235.28 | $317.95 |