- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.11 / $115.62 / $2,412.86
| Professional | | $65.11 | $115.62 | $2,412.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.07 / $628.07 / $628.07
| Facility | | $628.07 | $628.07 | $628.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.05 / $140.55 / $843.31
| Professional | | $128.05 | $140.55 | $843.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $628.07 / $628.07 / $628.07
| Facility | | $628.07 | $628.07 | $628.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.05 / $140.55 / $843.31
| Professional | | $128.05 | $140.55 | $843.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.94 / $163.91 / $1,688.63
| Professional | | $55.94 | $163.91 | $1,688.63 |