- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.45 / $355.45 / $410.14
| Professional | | $355.45 | $355.45 | $410.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.71 / $408.71 / $535.36
| Facility | | $408.71 | $408.71 | $535.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.36 / $408.71 / $420.97
| Professional | | $298.36 | $408.71 | $420.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $408.71 / $408.71 / $535.36
| Facility | | $408.71 | $408.71 | $535.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.36 / $408.71 / $420.97
| Professional | | $298.36 | $408.71 | $420.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.95 / $431.48 / $842.07
| Professional | | $251.95 | $431.48 | $842.07 |