- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.80 / $196.80 / $227.08
| Professional | | $196.80 | $196.80 | $227.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.27 / $326.27 / $326.27
| Professional | | $326.27 | $326.27 | $326.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.88 / $260.88 / $296.42
| Facility | | $260.88 | $260.88 | $296.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.44 / $260.88 / $278.11
| Professional | | $190.44 | $260.88 | $278.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.88 / $260.88 / $296.42
| Facility | | $260.88 | $260.88 | $296.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.44 / $260.88 / $278.11
| Professional | | $190.44 | $260.88 | $278.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.13 / $303.07 / $466.22
| Professional | | $134.13 | $303.07 | $466.22 |