- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $524.81 / $707.95
| Professional | | $407.38 | $524.81 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $398.11
| Facility | | $331.13 | $331.13 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $331.13 / $398.11
| Professional | | $281.84 | $331.13 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $22.91 / $218.78 / $331.13
| Facility | | $22.91 | $218.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $169.82 / $295.12 / $549.54
| Professional | | $169.82 | $295.12 | $549.54 |