- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $524.81
| Professional | | $281.84 | $354.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $446.68 / $446.68
| Professional | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $407.38 / $645.65
| Professional | | $46.77 | $407.38 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $26.30 / $165.96 / $371.54
| Facility | | $26.30 | $165.96 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.96 / $251.19 / $371.54
| Professional | | $165.96 | $251.19 | $371.54 |