- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.95 / $361.29 / $1,873.44
| Professional | | $203.95 | $361.29 | $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
- $138.55 / $329.43 / $654.37
| Professional | | $138.55 | $329.43 | $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
- $138.55 / $329.43 / $654.37
| Professional | | $138.55 | $329.43 | $654.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.27 / $291.80 / $1,311.12
| Professional | | $127.27 | $291.80 | $1,311.12 |