- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.76 / $272.76 / $314.72
| Professional | | $272.76 | $272.76 | $314.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.57 / $373.57 / $410.82
| Facility | | $373.57 | $373.57 | $410.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.70 / $373.57 / $384.78
| Professional | | $272.70 | $373.57 | $384.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.57 / $373.57 / $410.82
| Facility | | $373.57 | $373.57 | $410.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.70 / $373.57 / $384.78
| Professional | | $272.70 | $373.57 | $384.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $276.36 / $276.36 / $348.56
| Facility | | $276.36 | $276.36 | $348.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.90 / $353.80 / $646.16
| Professional | | $185.90 | $353.80 | $646.16 |