- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.34 / $183.34 / $321.08
| Professional | | $183.34 | $183.34 | $321.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $358.08 / $358.08 / $358.08
| Facility | | $358.08 | $358.08 | $358.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $358.08 / $358.08 / $358.08
| Professional | | $358.08 | $358.08 | $358.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.83 / $302.83 / $499.81
| Facility | | $302.83 | $302.83 | $499.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.41 / $257.41 / $302.83
| Professional | | $257.41 | $257.41 | $302.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.37 / $224.66 / $224.66
| Facility | | $128.37 | $224.66 | $224.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.66 / $226.68 / $261.98
| Professional | | $153.66 | $226.68 | $261.98 |