- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.10 / $249.10 / $389.50
| Professional | | $249.10 | $249.10 | $389.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $434.40 / $434.40 / $434.40
| Facility | | $434.40 | $434.40 | $434.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.40 / $434.40 / $434.40
| Professional | | $434.40 | $434.40 | $434.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.92 / $230.92 / $437.70
| Facility | | $230.92 | $230.92 | $437.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $168.57 / $168.57 / $230.92
| Professional | | $168.57 | $168.57 | $230.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.63 / $184.37 / $204.69
| Professional | | $166.63 | $184.37 | $204.69 |