- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.15 / $330.72 / $330.72
| Professional | | $234.15 | $330.72 | $330.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.13 / $332.93 / $332.93
| Facility | | $245.13 | $332.93 | $332.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.86 / $332.93 / $656.25
| Professional | | $39.86 | $332.93 | $656.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.10 / $330.72 / $449.94
| Facility | | $172.10 | $330.72 | $449.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.44 / $472.44 / $472.44
| Professional | | $472.44 | $472.44 | $472.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.86 / $258.76 / $449.94
| Professional | | $184.86 | $258.76 | $449.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.46 / $1,933.58 / $1,933.58
| Facility | | $496.46 | $1,933.58 | $1,933.58 |