- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $446.68
| Professional | | $407.38 | $407.38 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $346.74 / $436.52
| Professional | | $295.12 | $346.74 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $426.58 / $831.76
| Facility | | $407.38 | $426.58 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $831.76 / $831.76 / $831.76
| Professional | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.67 / $39.81 / $60.26
| Professional | | $34.67 | $39.81 | $60.26 |