- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.68 / $247.40 / $312.45
| Professional | | $173.68 | $247.40 | $312.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.83 / $357.47 / $357.47
| Professional | | $303.83 | $357.47 | $357.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $401.63 / $401.63 / $401.63
| Facility | | $401.63 | $401.63 | $401.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.83 / $170.83 / $170.83
| Facility | | $170.83 | $170.83 | $170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.21 / $170.83 / $170.83
| Professional | | $145.21 | $170.83 | $170.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.00 / $784.00 / $784.00
| Professional | | $784.00 | $784.00 | $784.00 |