- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $215.23 / $338.91
| Professional | | $172.18 | $215.23 | $338.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.10 / $282.10 / $282.10
| Facility | | $282.10 | $282.10 | $282.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $396.00 / $1,297.00 / $1,297.00
| Professional | | $396.00 | $1,297.00 | $1,297.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.22 / $148.22 / $233.86
| Facility | | $148.22 | $148.22 | $233.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.71 / $231.00 / $250.22
| Professional | | $152.71 | $231.00 | $250.22 |