- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.03 / $244.52 / $1,242.59
| Professional | | $138.03 | $244.52 | $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
- $94.48 / $271.36 / $433.82
| Professional | | $94.48 | $271.36 | $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
- $94.48 / $224.65 / $433.82
| Professional | | $94.48 | $224.65 | $433.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.41 / $197.48 / $869.63
| Professional | | $84.41 | $197.48 | $869.63 |