- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.54 / $317.99 / $352.38
| Professional | | $193.54 | $317.99 | $352.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.93 / $395.93 / $395.93
| Professional | | $395.93 | $395.93 | $395.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $304.86 / $340.50 / $463.43
| Facility | | $304.86 | $340.50 | $463.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.45 / $215.53 / $457.74
| Professional | | $121.45 | $215.53 | $457.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.45 / $182.18 / $261.36
| Professional | | $121.45 | $182.18 | $261.36 |