- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.35 / $195.35 / $252.37
| Professional | | $195.35 | $195.35 | $252.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.87 / $323.87 / $323.87
| Professional | | $323.87 | $323.87 | $323.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.60 / $252.60 / $294.23
| Facility | | $252.60 | $252.60 | $294.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.40 / $184.40 / $249.36
| Professional | | $184.40 | $184.40 | $249.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.60 / $252.60 / $294.23
| Facility | | $252.60 | $252.60 | $294.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.40 / $184.40 / $249.36
| Professional | | $184.40 | $184.40 | $249.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.47 / $237.13 / $462.79
| Professional | | $138.47 | $237.13 | $462.79 |