- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $331.13 / $575.44
| Professional | | $323.59 | $331.13 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $562.34
| Facility | | $407.38 | $407.38 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $407.38
| Professional | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.38 / $181.97 / $446.68
| Facility | | $21.38 | $181.97 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $281.84 / $446.68
| Professional | | $204.17 | $281.84 | $446.68 |