- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $724.44
| Professional | | $616.60 | $616.60 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $169.82 / $177.83
| Professional | | $169.82 | $169.82 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $263.03 / $389.05
| Facility | | $190.55 | $263.03 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $194.98 / $263.03 / $398.11
| Facility | | $194.98 | $263.03 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |