- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $398.11 / $537.03 / $537.03
| Professional | | $398.11 | $537.03 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $275.42 / $1,122.02
| Professional | | $204.17 | $275.42 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $512.86 / $537.03 / $645.65
| Facility | | $512.86 | $537.03 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $33.11 / $257.04 / $501.19
| Facility | | $33.11 | $257.04 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $407.38 / $660.69
| Professional | | $257.04 | $407.38 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $3,630.78 / $3,630.78
| Facility | | $1,174.90 | $3,630.78 | $3,630.78 |