- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.86 / $311.27 / $311.27
| Professional | | $268.86 | $311.27 | $311.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.42 / $360.42 / $360.42
| Professional | | $360.42 | $360.42 | $360.42 |
- 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 / $346.64 / $407.81
| Professional | | $47.24 | $346.64 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.03 / $291.07 / $387.22
| Professional | | $186.03 | $291.07 | $387.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.29 / $491.16 / $625.11
| Professional | | $443.29 | $491.16 | $625.11 |