- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.48 / $318.48 / $363.06
| Professional | | $290.48 | $318.48 | $363.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.24 / $403.24 / $403.24
| Facility | | $403.24 | $403.24 | $403.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.52 / $289.52 / $554.05
| Professional | | $289.52 | $289.52 | $554.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.48 / $318.48 / $363.06
| Professional | | $290.48 | $318.48 | $363.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.24 / $403.24 / $403.24
| Facility | | $403.24 | $403.24 | $403.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.52 / $443.25 / $554.05
| Professional | | $289.52 | $443.25 | $554.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.05 / $355.11 / $553.91
| Professional | | $321.05 | $355.11 | $553.91 |