- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $446.68 / $741.31
| Professional | | $323.59 | $446.68 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $575.44 / $575.44 / $1,380.38
| Facility | | $575.44 | $575.44 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.87 / $416.87 / $1,023.29
| Professional | | $416.87 | $416.87 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $501.19 / $575.44 / $1,047.13
| Facility | | $501.19 | $575.44 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $380.19 / $588.84
| Professional | | $257.04 | $380.19 | $588.84 |