- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.37 / $351.90 / $517.36
| Professional | | $338.37 | $351.90 | $517.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $70.06 / $70.06 / $70.06
| Facility | | $70.06 | $70.06 | $70.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.86 / $51.86 / $51.86
| Professional | | $51.86 | $51.86 | $51.86 |
- 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
- $186.22 / $232.78 / $379.51
| Professional | | $186.22 | $232.78 | $379.51 |