- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.74 / $103.74 / $1,959.93
| Professional | | $103.74 | $103.74 | $1,959.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.18 / $510.18 / $510.18
| Facility | | $510.18 | $510.18 | $510.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $685.19 / $685.19 / $685.19
| Professional | | $685.19 | $685.19 | $685.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.18 / $510.18 / $510.18
| Facility | | $510.18 | $510.18 | $510.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $685.19
| Professional | | $150.00 | $150.00 | $685.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.02 / $304.81 / $704.23
| Professional | | $128.02 | $304.81 | $704.23 |