- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.75 / $235.16 / $251.48
| Professional | | $179.75 | $235.16 | $251.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $485.00 / $485.00 / $513.90
| Facility | | $485.00 | $485.00 | $513.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.11 / $288.12 / $383.13
| Professional | | $252.11 | $288.12 | $383.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,118.00 / $2,118.00 / $2,118.00
| Facility | | $2,118.00 | $2,118.00 | $2,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.40 / $251.61 / $493.11
| Professional | | $206.40 | $251.61 | $493.11 |