- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.53 / $223.25 / $273.70
| Professional | | $183.53 | $223.25 | $273.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.48 / $315.48 / $375.00
| Facility | | $315.48 | $315.48 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.48 / $315.48 / $474.00
| Professional | | $315.48 | $315.48 | $474.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.30 / $315.48 / $442.14
| Facility | | $222.30 | $315.48 | $442.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.48 / $315.48 / $474.00
| Professional | | $315.48 | $315.48 | $474.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.75 / $319.75 / $667.10
| Professional | | $319.75 | $319.75 | $667.10 |