- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.24 / $188.60 / $1,273.08
| Professional | | $104.24 | $188.60 | $1,273.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.38 / $331.38 / $331.38
| Facility | | $331.38 | $331.38 | $331.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.84 / $407.59 / $494.63
| Professional | | $370.84 | $407.59 | $494.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.38 / $331.38 / $331.38
| Facility | | $331.38 | $331.38 | $331.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $407.59 / $494.63
| Professional | | $145.00 | $407.59 | $494.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.48 / $162.07 / $457.44
| Professional | | $86.48 | $162.07 | $457.44 |