- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.92 / $283.92 / $327.60
| Professional | | $283.92 | $283.92 | $327.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.70 / $470.70 / $470.70
| Professional | | $470.70 | $470.70 | $470.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.77 / $311.77 / $427.63
| Facility | | $311.77 | $311.77 | $427.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.60 / $311.77 / $332.37
| Professional | | $227.60 | $311.77 | $332.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.77 / $311.77 / $427.63
| Facility | | $311.77 | $311.77 | $427.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.60 / $311.77 / $332.37
| Professional | | $227.60 | $311.77 | $332.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.50 / $344.65 / $672.61
| Professional | | $193.50 | $344.65 | $672.61 |