- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.43 / $193.85 / $1,691.03
| Professional | | $109.43 | $193.85 | $1,691.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.17 / $440.17 / $440.17
| Facility | | $440.17 | $440.17 | $440.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.24 / $331.06 / $591.13
| Professional | | $139.24 | $331.06 | $591.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $440.17 / $440.17 / $440.17
| Facility | | $440.17 | $440.17 | $440.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.24 / $331.06 / $591.13
| Professional | | $139.24 | $331.06 | $591.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.80 / $218.86 / $607.61
| Professional | | $93.80 | $218.86 | $607.61 |