- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.72 / $203.75 / $1,873.44
| Professional | | $133.72 | $203.75 | $1,873.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.65 / $487.65 / $487.65
| Facility | | $487.65 | $487.65 | $487.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $400.88 / $440.56 / $654.37
| Professional | | $400.88 | $440.56 | $654.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $487.65 / $487.65 / $487.65
| Facility | | $487.65 | $487.65 | $487.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $440.56 / $654.37
| Professional | | $90.00 | $440.56 | $654.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.27 / $343.78 / $1,311.12
| Professional | | $127.27 | $343.78 | $1,311.12 |