- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.05 / $1,767.16 / $1,767.16
| Professional | | $316.05 | $1,767.16 | $1,767.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.27 / $368.27 / $368.27
| Professional | | $368.27 | $368.27 | $368.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.50 / $467.21 / $1,566.53
| Facility | | $398.50 | $467.21 | $1,566.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.80 / $398.50 / $398.50
| Professional | | $129.80 | $398.50 | $398.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.50 / $467.21 / $1,566.53
| Facility | | $398.50 | $467.21 | $1,566.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.35 / $247.35 / $398.50
| Professional | | $247.35 | $247.35 | $398.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.43 / $115.43 / $274.83
| Professional | | $115.43 | $115.43 | $274.83 |