- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $350.77 / $1,818.92
| Professional | | $198.02 | $350.77 | $1,818.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.47 / $473.47 / $473.47
| Facility | | $473.47 | $473.47 | $473.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.61 / $320.06 / $635.72
| Professional | | $134.61 | $320.06 | $635.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $473.47 / $473.47 / $473.47
| Facility | | $473.47 | $473.47 | $473.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.61 / $320.06 / $635.72
| Professional | | $134.61 | $320.06 | $635.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.56 / $282.88 / $653.57
| Professional | | $123.56 | $282.88 | $653.57 |