- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.08 / $350.81 / $350.81
| Professional | | $308.08 | $350.81 | $350.81 |
- 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
- $45.14 / $84.64 / $524.76
| Professional | | $45.14 | $84.64 | $524.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.71 / $325.52 / $511.54
| Facility | | $181.71 | $325.52 | $511.54 |
- 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
- $223.23 / $279.33 / $345.16
| Professional | | $223.23 | $279.33 | $345.16 |