- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.75 / $286.75 / $330.87
| Professional | | $286.75 | $286.75 | $330.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.70 / $315.70 / $431.89
| Facility | | $315.70 | $315.70 | $431.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.47 / $315.70 / $336.56
| Professional | | $230.47 | $315.70 | $336.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.70 / $315.70 / $431.89
| Facility | | $315.70 | $315.70 | $431.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.47 / $315.70 / $336.56
| Professional | | $230.47 | $315.70 | $336.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.44 / $348.09 / $679.32
| Professional | | $195.44 | $348.09 | $679.32 |