- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $524.81 / $660.69
| Professional | | $346.74 | $524.81 | $660.69 |
- 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
- $77.62 / $457.09 / $5,128.61
| Facility | | $77.62 | $457.09 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $478.63 / $691.83
| Professional | | $316.23 | $478.63 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.65 / $331.13 / $758.58
| Facility | | $43.65 | $331.13 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $478.63 / $691.83
| Professional | | $354.81 | $478.63 | $691.83 |