- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.57 / $395.28 / $395.28
| Professional | | $286.57 | $395.28 | $395.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.81 / $407.81 / $407.81
| Facility | | $407.81 | $407.81 | $407.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $49.27 / $407.81 / $815.63
| Professional | | $49.27 | $407.81 | $815.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $43.00 / $395.28 / $463.67
| Facility | | $43.00 | $395.28 | $463.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.00 / $338.48 / $338.48
| Professional | | $43.00 | $338.48 | $338.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.22 / $249.14 / $405.23
| Professional | | $186.22 | $249.14 | $405.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $607.91 / $3,087.50 / $3,087.50
| Facility | | $607.91 | $3,087.50 | $3,087.50 |