- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $512.86
| Professional | | $407.38 | $407.38 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $575.44
| Professional | | $346.74 | $346.74 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $562.34
| Professional | | $562.34 | $562.34 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.38 / $426.58 / $691.83
| Facility | | $407.38 | $426.58 | $691.83 |