- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $125.16 / $1,127.82
| Professional | | $75.00 | $125.16 | $1,127.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.24 / $270.27 / $394.08
| Professional | | $246.24 | $270.27 | $394.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $270.27 / $394.08
| Professional | | $60.00 | $270.27 | $394.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.61 / $179.25 / $405.24
| Professional | | $76.61 | $179.25 | $405.24 |