- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.91 / $309.91 / $357.59
| Professional | | $309.91 | $309.91 | $357.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.62 / $297.62 / $466.77
| Facility | | $297.62 | $297.62 | $466.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $297.62 / $317.27
| Professional | | $217.26 | $297.62 | $317.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.62 / $297.62 / $466.77
| Facility | | $297.62 | $297.62 | $466.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.26 / $297.62 / $317.27
| Professional | | $217.26 | $297.62 | $317.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.22 / $376.19 / $734.17
| Professional | | $211.22 | $376.19 | $734.17 |