- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.05 / $217.05 / $217.05
| Professional | | $217.05 | $217.05 | $217.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64,999.99 / $81,499.99 / $94,999.99
| Facility | | $64,999.99 | $81,499.99 | $94,999.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.29 / $760.51 / $1,937.96
| Facility | | $291.29 | $760.51 | $1,937.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $143.26 / $291.29
| Professional | | $143.26 | $143.26 | $291.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $291.29 / $760.51 / $1,937.96
| Facility | | $291.29 | $760.51 | $1,937.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.26 / $348.36 / $496.06
| Professional | | $143.26 | $348.36 | $496.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,170.19 / $2,170.19 / $2,170.19
| Professional | | $2,170.19 | $2,170.19 | $2,170.19 |