- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $602.56 / $851.14
| Professional | | $199.53 | $602.56 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $436.52 / $1,445.44
| Professional | | $398.11 | $436.52 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $645.65 / $645.65
| Professional | | $288.40 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $389.05 / $1,479.11
| Professional | | $173.78 | $389.05 | $1,479.11 |