- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $329.18 / $584.59 / $2,222.02
| Professional | | $329.18 | $584.59 | $2,222.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.40 / $578.40 / $578.40
| Facility | | $578.40 | $578.40 | $578.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.61 / $711.38 / $862.77
| Professional | | $647.61 | $711.38 | $862.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $578.40 / $578.40 / $578.40
| Facility | | $578.40 | $578.40 | $578.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.31 / $711.38 / $862.77
| Professional | | $277.31 | $711.38 | $862.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.94 / $471.44 / $1,555.07
| Professional | | $150.94 | $471.44 | $1,555.07 |