- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.18 / $269.18 / $310.58
| Professional | | $269.18 | $269.18 | $310.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.22 / $344.22 / $405.42
| Facility | | $344.22 | $344.22 | $405.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.28 / $344.22 / $354.55
| Professional | | $251.28 | $344.22 | $354.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.22 / $344.22 / $405.42
| Facility | | $344.22 | $344.22 | $405.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.28 / $344.22 / $354.55
| Professional | | $251.28 | $344.22 | $354.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.80 / $376.95 / $637.67
| Professional | | $190.80 | $376.95 | $637.67 |