- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.74 / $318.64 / $398.31
| Professional | | $173.74 | $318.64 | $398.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.57 / $253.57 / $1,300.00
| Facility | | $253.57 | $253.57 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.00 / $1,017.00 / $1,157.05
| Professional | | $347.00 | $1,017.00 | $1,157.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.06 / $153.06 / $222.79
| Facility | | $153.06 | $153.06 | $222.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.06 / $214.47 / $280.99
| Professional | | $153.06 | $214.47 | $280.99 |