- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.62 / $785.17 / $1,333.97
| Professional | | $197.62 | $785.17 | $1,333.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.24 / $347.24 / $347.24
| Facility | | $347.24 | $347.24 | $347.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.57 / $427.05 / $518.15
| Professional | | $388.57 | $427.05 | $518.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $347.24 / $347.24 / $347.24
| Facility | | $347.24 | $347.24 | $347.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $427.05 / $518.15
| Professional | | $145.00 | $427.05 | $518.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.62 / $283.02 / $933.57
| Professional | | $90.62 | $283.02 | $933.57 |