- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.09 / $511.16 / $526.49
| Professional | | $408.09 | $511.16 | $526.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.43 / $514.71 / $1,158.59
| Professional | | $408.43 | $514.71 | $1,158.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $654.00 / $654.75 / $654.75
| Facility | | $654.00 | $654.75 | $654.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.35 / $654.75 / $750.00
| Professional | | $44.35 | $654.75 | $750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.40 / $50.40 / $50.40
| Professional | | $50.40 | $50.40 | $50.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.31 / $397.78 / $690.83
| Professional | | $342.31 | $397.78 | $690.83 |