- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.82 / $224.76 / $283.89
| Professional | | $167.82 | $224.76 | $283.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.19 / $308.19 / $308.19
| Professional | | $308.19 | $308.19 | $308.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.45 / $263.45 / $325.44
| Facility | | $263.45 | $263.45 | $325.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.93 / $223.93 / $223.93
| Professional | | $223.93 | $223.93 | $223.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.45 / $263.45 / $325.44
| Facility | | $263.45 | $263.45 | $325.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.72 / $261.58 / $347.69
| Professional | | $125.72 | $261.58 | $347.69 |