- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.78 / $173.50 / $1,308.51
| Professional | | $154.78 | $173.50 | $1,308.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.62 / $340.62 / $340.62
| Facility | | $340.62 | $340.62 | $340.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.35 / $334.61 / $457.33
| Professional | | $304.35 | $334.61 | $457.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.62 / $340.62 / $340.62
| Facility | | $340.62 | $340.62 | $340.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $132.28 / $334.61 / $457.33
| Professional | | $132.28 | $334.61 | $457.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.89 / $221.66 / $915.75
| Professional | | $88.89 | $221.66 | $915.75 |