- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.79 / $265.79 / $465.46
| Professional | | $265.79 | $265.79 | $465.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.11 / $519.11 / $519.11
| Facility | | $519.11 | $519.11 | $519.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.11 / $519.11 / $519.11
| Professional | | $519.11 | $519.11 | $519.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.68 / $252.68 / $444.81
| Facility | | $252.68 | $252.68 | $444.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.10 / $194.10 / $252.68
| Professional | | $194.10 | $194.10 | $252.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.33 / $268.98 / $310.86
| Professional | | $182.33 | $268.98 | $310.86 |