- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.93 / $866.47 / $2,139.36
| Professional | | $205.93 | $866.47 | $2,139.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $257.12 / $257.12 / $257.12
| Facility | | $257.12 | $257.12 | $257.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.12 / $277.02 / $602.95
| Professional | | $257.12 | $277.02 | $602.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.52 / $718.25 / $752.04
| Facility | | $159.52 | $718.25 | $752.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.54 / $374.61 / $624.39
| Professional | | $167.54 | $374.61 | $624.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.62 / $668.48 / $1,060.06
| Professional | | $558.62 | $668.48 | $1,060.06 |