- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.05 / $366.78 / $1,901.93
| Professional | | $207.05 | $366.78 | $1,901.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.07 / $495.07 / $495.07
| Facility | | $495.07 | $495.07 | $495.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.94 / $335.14 / $664.92
| Professional | | $140.94 | $335.14 | $664.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $495.07 / $495.07 / $495.07
| Facility | | $495.07 | $495.07 | $495.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.94 / $335.14 / $664.92
| Professional | | $140.94 | $335.14 | $664.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.19 / $296.22 / $683.39
| Professional | | $129.19 | $296.22 | $683.39 |