- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.25 / $252.61 / $1,110.65
| Professional | | $142.25 | $252.61 | $1,110.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.10 / $289.10 / $289.10
| Facility | | $289.10 | $289.10 | $289.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.73 / $307.58 / $388.41
| Professional | | $279.73 | $307.58 | $388.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $289.10 / $289.10 / $289.10
| Facility | | $289.10 | $289.10 | $289.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.00 / $307.58 / $388.41
| Professional | | $110.00 | $307.58 | $388.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.45 / $203.80 / $777.29
| Professional | | $75.45 | $203.80 | $777.29 |