- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.25 / $192.25 / $218.46
| Professional | | $192.25 | $192.25 | $218.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.35 / $2,379.35 / $2,379.35
| Facility | | $2,379.35 | $2,379.35 | $2,379.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $481.59 / $481.59 / $481.59
| Professional | | $481.59 | $481.59 | $481.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.40 / $58.40 / $58.40
| Professional | | $58.40 | $58.40 | $58.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.35 / $2,379.35 / $2,379.35
| Facility | | $2,379.35 | $2,379.35 | $2,379.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.21 / $481.59 / $481.59
| Professional | | $255.21 | $481.59 | $481.59 |