- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.89 / $264.89 / $305.64
| Professional | | $264.89 | $264.89 | $305.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.10 / $365.10 / $398.97
| Facility | | $365.10 | $365.10 | $398.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.52 / $327.33 / $376.05
| Professional | | $266.52 | $327.33 | $376.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $365.10 / $365.10 / $398.97
| Facility | | $365.10 | $365.10 | $398.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $266.52 / $365.10 / $376.05
| Professional | | $266.52 | $365.10 | $376.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.55 / $362.30 / $627.54
| Professional | | $180.55 | $362.30 | $627.54 |