- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.04 / $361.36 / $361.36
| Professional | | $233.04 | $361.36 | $361.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.62 / $327.62 / $327.62
| Facility | | $327.62 | $327.62 | $327.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.42 / $327.62 / $551.25
| Professional | | $42.42 | $327.62 | $551.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $197.59 / $361.36 / $516.57
| Facility | | $197.59 | $361.36 | $516.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $542.40 / $542.40 / $542.40
| Professional | | $542.40 | $542.40 | $542.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.59 / $284.11 / $460.58
| Professional | | $197.59 | $284.11 | $460.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $569.97 / $1,924.42 / $1,924.42
| Facility | | $569.97 | $1,924.42 | $1,924.42 |