- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.00 / $405.74 / $1,496.24
| Professional | | $174.00 | $405.74 | $1,496.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $265.52 / $265.52 / $265.52
| Facility | | $265.52 | $265.52 | $265.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.38 / $265.52 / $471.12
| Professional | | $153.38 | $265.52 | $471.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.76 / $237.04 / $348.00
| Facility | | $132.76 | $237.04 | $348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.30 / $340.90 / $550.69
| Professional | | $214.30 | $340.90 | $550.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.26 / $448.56 / $626.00
| Professional | | $375.26 | $448.56 | $626.00 |