- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.98 / $299.88 / $299.88
| Professional | | $198.98 | $299.88 | $299.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.44 / $348.44 / $348.44
| Professional | | $348.44 | $348.44 | $348.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.81 / $382.81 / $382.81
| Facility | | $382.81 | $382.81 | $382.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.29 / $382.81 / $382.81
| Professional | | $40.29 | $382.81 | $382.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.41 / $225.63 / $411.79
| Professional | | $150.41 | $225.63 | $411.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.25 / $442.35 / $563.00
| Professional | | $399.25 | $442.35 | $563.00 |