- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $602.56 / $831.76
| Professional | | $426.58 | $602.56 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $426.58 / $1,122.02
| Professional | | $77.62 | $426.58 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.02 / $288.40 / $562.34
| Facility | | $38.02 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $398.11 / $630.96
| Professional | | $288.40 | $398.11 | $630.96 |