- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.38 / $340.79 / $1,767.16
| Professional | | $192.38 | $340.79 | $1,767.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.00 / $460.00 / $460.00
| Facility | | $460.00 | $460.00 | $460.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.84 / $311.08 / $617.88
| Professional | | $130.84 | $311.08 | $617.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $460.00 / $460.00 / $460.00
| Facility | | $460.00 | $460.00 | $460.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.84 / $311.08 / $617.88
| Professional | | $130.84 | $311.08 | $617.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.05 / $324.27 / $634.97
| Professional | | $120.05 | $324.27 | $634.97 |