- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.38 / $277.38 / $280.08
| Professional | | $277.38 | $277.38 | $280.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.31 / $303.31 / $346.28
| Professional | | $303.31 | $303.31 | $346.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.56 / $1,436.33 / $3,484.44
| Facility | | $333.56 | $1,436.33 | $3,484.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.77 / $262.52 / $676.00
| Professional | | $218.77 | $262.52 | $676.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $333.56 / $1,147.45 / $1,674.85
| Facility | | $333.56 | $1,147.45 | $1,674.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.31 / $370.63 / $624.24
| Professional | | $303.31 | $370.63 | $624.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.77 / $251.59 / $449.79
| Professional | | $218.77 | $251.59 | $449.79 |