- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.78 / $217.50 / $1,127.82
| Professional | | $122.78 | $217.50 | $1,127.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.51 / $198.56 / $394.08
| Professional | | $83.51 | $198.56 | $394.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.58 / $293.58 / $293.58
| Facility | | $293.58 | $293.58 | $293.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.51 / $198.56 / $394.08
| Professional | | $83.51 | $198.56 | $394.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $76.61 / $179.25 / $789.30
| Professional | | $76.61 | $179.25 | $789.30 |