- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.43 / $296.25 / $2,087.05
| Professional | | $230.43 | $296.25 | $2,087.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.27 / $543.27 / $543.27
| Facility | | $543.27 | $543.27 | $543.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.08 / $497.86 / $728.97
| Professional | | $453.08 | $497.86 | $728.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $543.27 / $543.27 / $543.27
| Facility | | $543.27 | $543.27 | $543.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.00 / $497.86 / $728.97
| Professional | | $135.00 | $497.86 | $728.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.32 / $330.01 / $749.91
| Professional | | $136.32 | $330.01 | $749.91 |