- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.19 / $870.96 / $1,071.52
| Professional | | $501.19 | $870.96 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $346.74 / $1,659.59
| Professional | | $100.00 | $346.74 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $354.81 / $794.33
| Facility | | $56.23 | $354.81 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $524.81 / $794.33
| Professional | | $354.81 | $524.81 | $794.33 |