- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.83 / $268.83 / $420.35
| Professional | | $268.83 | $268.83 | $420.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $468.80 / $468.80 / $468.80
| Facility | | $468.80 | $468.80 | $468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.80 / $468.80 / $468.80
| Professional | | $468.80 | $468.80 | $468.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $352.55 / $352.55 / $533.25
| Facility | | $352.55 | $352.55 | $533.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.36 / $257.36 / $352.55
| Professional | | $257.36 | $257.36 | $352.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.36 / $229.42 / $254.70
| Professional | | $207.36 | $229.42 | $254.70 |