- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.07 / $364.16 / $1,794.94
| Professional | | $307.07 | $364.16 | $1,794.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.72 / $554.72 / $554.72
| Professional | | $554.72 | $554.72 | $554.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $554.72 / $554.72 / $554.72
| Facility | | $554.72 | $554.72 | $554.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $280.13 / $554.72 / $562.79
| Professional | | $280.13 | $554.72 | $562.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.66 / $372.44 / $554.72
| Facility | | $275.66 | $372.44 | $554.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.94 / $551.60 / $716.38
| Professional | | $330.94 | $551.60 | $716.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.66 / $553.32 / $705.92
| Professional | | $459.66 | $553.32 | $705.92 |