- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $432.26 / $432.26 / $432.26
| Professional | | $432.26 | $432.26 | $432.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.40 / $165.40 / $165.40
| Facility | | $165.40 | $165.40 | $165.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.74 / $165.40 / $176.33
| Professional | | $120.74 | $165.40 | $176.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.25 / $85.25 / $85.25
| Facility | | $85.25 | $85.25 | $85.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.55 / $479.38 / $756.92
| Professional | | $262.55 | $479.38 | $756.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.25 / $85.25 / $165.40
| Facility | | $85.25 | $85.25 | $165.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.74 / $176.33 / $323.87
| Professional | | $120.74 | $176.33 | $323.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.07 / $377.61 / $629.36
| Professional | | $243.07 | $377.61 | $629.36 |