- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.08 / $1,328.66 / $1,328.66
| Professional | | $383.08 | $1,328.66 | $1,328.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.61 / $338.61 / $338.61
| Professional | | $338.61 | $338.61 | $338.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $232.98 / $364.08 / $364.08
| Facility | | $232.98 | $364.08 | $364.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.98 / $296.07 / $364.08
| Professional | | $232.98 | $296.07 | $364.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.31 / $346.74 / $364.08
| Facility | | $193.31 | $346.74 | $364.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.98 / $273.25 / $364.33
| Professional | | $232.98 | $273.25 | $364.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.34 / $172.98 / $266.56
| Professional | | $156.34 | $172.98 | $266.56 |