- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.93 / $257.04 / $1,819.70
| Professional | | $208.93 | $257.04 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $467.74 / $1,548.82
| Facility | | $398.11 | $467.74 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $128.82 / $398.11
| Professional | | $128.82 | $128.82 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $371.54 / $831.76
| Facility | | $275.42 | $371.54 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $371.54 / $831.76
| Professional | | $275.42 | $371.54 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $467.74 / $1,548.82
| Facility | | $245.47 | $467.74 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $436.52
| Professional | | $245.47 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.82 / $114.82 / $275.42
| Professional | | $114.82 | $114.82 | $275.42 |