- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.46 / $325.70 / $325.70
| Professional | | $234.46 | $325.70 | $325.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.25 / $618.32 / $1,146.18
| Facility | | $477.25 | $618.32 | $1,146.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.32 / $342.43 / $342.43
| Professional | | $326.32 | $342.43 | $342.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.13 / $347.13 / $394.40
| Facility | | $347.13 | $347.13 | $394.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.40 / $253.40 / $347.13
| Professional | | $253.40 | $253.40 | $347.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $434.47 / $434.47 / $434.47
| Professional | | $434.47 | $434.47 | $434.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.14 / $325.70 / $325.70
| Professional | | $302.14 | $325.70 | $325.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.47 / $267.70 / $615.64
| Professional | | $178.47 | $267.70 | $615.64 |