- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $660.69 / $1,318.26
| Professional | | $331.13 | $660.69 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $56.23 / $1,288.25
| Facility | | $54.95 | $56.23 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $288.40 / $467.74
| Facility | | $199.53 | $288.40 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $234.42
| Professional | | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.53 / $288.40 / $467.74
| Facility | | $199.53 | $288.40 | $467.74 |