- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.28 / $239.63 / $1,242.59
| Professional | | $135.28 | $239.63 | $1,242.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.45 / $323.45 / $323.45
| Facility | | $323.45 | $323.45 | $323.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.08 / $218.94 / $433.82
| Professional | | $92.08 | $218.94 | $433.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.45 / $323.45 / $323.45
| Facility | | $323.45 | $323.45 | $323.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.08 / $218.94 / $433.82
| Professional | | $92.08 | $218.94 | $433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.41 / $197.48 / $446.48
| Professional | | $84.41 | $197.48 | $446.48 |