- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.83 / $298.11 / $298.11
| Professional | | $130.83 | $298.11 | $298.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,563.03 / $1,563.03 / $1,563.03
| Facility | | $1,563.03 | $1,563.03 | $1,563.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.38 / $1,451.38 / $1,451.38
| Facility | | $1,451.38 | $1,451.38 | $1,451.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.97 / $319.13 / $549.82
| Professional | | $186.97 | $319.13 | $549.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,451.38 / $1,451.38 / $1,451.38
| Facility | | $1,451.38 | $1,451.38 | $1,451.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.97 / $319.13 / $549.82
| Professional | | $186.97 | $319.13 | $549.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.03 / $300.27 / $626.49
| Professional | | $146.03 | $300.27 | $626.49 |