- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.57 / $277.57 / $320.27
| Professional | | $277.57 | $277.57 | $320.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.06 / $477.88 / $477.88
| Facility | | $418.06 | $477.88 | $477.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.85 / $348.85 / $354.10
| Professional | | $348.85 | $348.85 | $354.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $418.06 / $477.88 / $477.88
| Facility | | $418.06 | $477.88 | $477.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.85 / $348.85 / $354.10
| Professional | | $348.85 | $348.85 | $354.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.66 / $427.46 / $472.94
| Professional | | $257.66 | $427.46 | $472.94 |