- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $397.37 / $397.37 / $397.37
| Professional | | $397.37 | $397.37 | $397.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.42 / $415.19 / $415.19
| Professional | | $360.42 | $415.19 | $415.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.24 / $407.81 / $407.81
| Professional | | $47.24 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.86 / $268.86 / $397.37
| Professional | | $268.86 | $268.86 | $397.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.19 / $279.27 / $717.27
| Professional | | $186.19 | $279.27 | $717.27 |