- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.69 / $284.69 / $328.49
| Professional | | $284.69 | $284.69 | $328.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.35 / $373.35 / $428.79
| Facility | | $373.35 | $373.35 | $428.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.55 / $373.35 / $384.55
| Professional | | $272.55 | $373.35 | $384.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.35 / $373.35 / $428.79
| Facility | | $373.35 | $373.35 | $428.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.55 / $373.35 / $384.55
| Professional | | $272.55 | $373.35 | $384.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.04 / $345.58 / $674.44
| Professional | | $194.04 | $345.58 | $674.44 |