- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.22 / $534.91 / $1,333.00
| Professional | | $301.22 | $534.91 | $1,333.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.98 / $346.98 / $346.98
| Facility | | $346.98 | $346.98 | $346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $517.34 / $592.45 / $650.84
| Professional | | $517.34 | $592.45 | $650.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.98 / $346.98 / $346.98
| Facility | | $346.98 | $346.98 | $346.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $592.45 / $650.84
| Professional | | $115.00 | $592.45 | $650.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.55 / $290.23 / $663.61
| Professional | | $90.55 | $290.23 | $663.61 |