- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.66 / $2,150.21 / $2,150.21
| Professional | | $293.66 | $2,150.21 | $2,150.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $373.57 / $674.48 / $674.48
| Facility | | $373.57 | $674.48 | $674.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.57 / $548.50 / $674.48
| Professional | | $373.57 | $548.50 | $674.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.62 / $642.36 / $674.48
| Facility | | $311.62 | $642.36 | $674.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.57 / $506.22 / $703.09
| Professional | | $373.57 | $506.22 | $703.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $348.56 / $364.85 / $364.85
| Facility | | $348.56 | $364.85 | $364.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.03 / $278.85 / $464.75
| Professional | | $252.03 | $278.85 | $464.75 |