- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.35 / $171.35 / $1,805.96
| Professional | | $171.35 | $171.35 | $1,805.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $353.90 / $353.90 / $353.90
| Facility | | $353.90 | $353.90 | $353.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.82 / $353.90 / $907.03
| Professional | | $300.82 | $353.90 | $907.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.30 / $411.24 / $596.21
| Professional | | $283.30 | $411.24 | $596.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.35 / $259.88 / $380.78
| Professional | | $171.35 | $259.88 | $380.78 |