- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.52 / $315.52 / $364.06
| Professional | | $315.52 | $315.52 | $364.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.12 / $523.12 / $523.12
| Professional | | $523.12 | $523.12 | $523.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.50 / $338.50 / $475.21
| Facility | | $338.50 | $338.50 | $475.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.11 / $338.50 / $360.86
| Professional | | $247.11 | $338.50 | $360.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.50 / $338.50 / $475.21
| Facility | | $338.50 | $338.50 | $475.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.11 / $338.50 / $360.86
| Professional | | $247.11 | $338.50 | $360.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.05 / $393.34 / $747.46
| Professional | | $215.05 | $393.34 | $747.46 |