- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.37 / $216.76 / $1,124.03
| Professional | | $122.37 | $216.76 | $1,124.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.60 / $292.60 / $292.60
| Facility | | $292.60 | $292.60 | $292.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.34 / $198.15 / $392.46
| Professional | | $83.34 | $198.15 | $392.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $292.60 / $292.60 / $292.60
| Facility | | $292.60 | $292.60 | $292.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.34 / $198.15 / $392.46
| Professional | | $83.34 | $198.15 | $392.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.36 / $175.08 / $786.65
| Professional | | $76.36 | $175.08 | $786.65 |