- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $351.88 / $351.88 / $406.01
| Professional | | $351.88 | $351.88 | $406.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.57 / $450.57 / $529.98
| Facility | | $450.57 | $450.57 | $529.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.92 / $450.57 / $480.33
| Professional | | $328.92 | $450.57 | $480.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $450.57 / $450.57 / $529.98
| Facility | | $450.57 | $450.57 | $529.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.92 / $450.57 / $480.33
| Professional | | $328.92 | $450.57 | $480.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.82 / $456.42 / $833.59
| Professional | | $239.82 | $456.42 | $833.59 |