- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.93 / $343.45 / $1,371.52
| Professional | | $105.93 | $343.45 | $1,371.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.02 / $357.02 / $357.02
| Facility | | $357.02 | $357.02 | $357.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.32 / $229.20 / $479.23
| Professional | | $208.32 | $229.20 | $479.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $357.02 / $357.02 / $357.02
| Facility | | $357.02 | $357.02 | $357.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.65 / $229.20 / $479.23
| Professional | | $138.65 | $229.20 | $479.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.03 / $151.71 / $959.85
| Professional | | $91.03 | $151.71 | $959.85 |