- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $800.30 / $1,071.83 / $1,071.83
| Professional | | $800.30 | $1,071.83 | $1,071.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $107.63 / $107.63
| Facility | | $107.63 | $107.63 | $107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $107.63 / $110.86
| Professional | | $91.49 | $107.63 | $110.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.63 / $107.63 / $107.63
| Facility | | $107.63 | $107.63 | $107.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.49 / $107.63 / $110.86
| Professional | | $91.49 | $107.63 | $110.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.31 / $143.05 / $815.36
| Professional | | $63.31 | $143.05 | $815.36 |