- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.77 / $375.77 / $375.77
| Professional | | $375.77 | $375.77 | $375.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.44 / $375.40 / $386.77
| Professional | | $348.44 | $375.40 | $386.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.81 / $382.81 / $517.83
| Facility | | $382.81 | $382.81 | $517.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.29 / $382.81 / $530.78
| Professional | | $40.29 | $382.81 | $530.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.27 / $272.27 / $375.77
| Professional | | $272.27 | $272.27 | $375.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.65 / $257.31 / $668.96
| Professional | | $144.65 | $257.31 | $668.96 |