- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $331.13 / $512.86
| Professional | | $257.04 | $331.13 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.63 / $478.63 / $1,047.13
| Facility | | $478.63 | $478.63 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $776.25
| Professional | | $346.74 | $346.74 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $338.84 / $776.25
| Facility | | $190.55 | $338.84 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $263.03 / $426.58
| Professional | | $190.55 | $263.03 | $426.58 |