- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.65 / $251.65 / $290.36
| Professional | | $251.65 | $251.65 | $290.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.86 / $360.86 / $379.03
| Facility | | $360.86 | $360.86 | $379.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.41 / $305.33 / $384.69
| Professional | | $260.41 | $305.33 | $384.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.86 / $360.86 / $379.03
| Facility | | $360.86 | $360.86 | $379.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.41 / $360.86 / $384.69
| Professional | | $260.41 | $360.86 | $384.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.51 / $387.54 / $428.77
| Professional | | $171.51 | $387.54 | $428.77 |