- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.34 / $164.34 / $164.34
| Professional | | $164.34 | $164.34 | $164.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $882.01 / $882.01 / $882.01
| Facility | | $882.01 | $882.01 | $882.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.03 / $445.03 / $445.03
| Facility | | $445.03 | $445.03 | $445.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.83 / $222.15 / $502.78
| Professional | | $169.83 | $222.15 | $502.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.03 / $445.03 / $445.03
| Facility | | $445.03 | $445.03 | $445.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.83 / $222.15 / $502.78
| Professional | | $169.83 | $222.15 | $502.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.80 / $251.15 / $364.68
| Professional | | $151.80 | $251.15 | $364.68 |