- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.68 / $201.68 / $252.10
| Professional | | $201.68 | $201.68 | $252.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.58 / $274.81 / $972.00
| Facility | | $190.58 | $274.81 | $972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $274.00 / $1,381.00 / $1,381.00
| Professional | | $274.00 | $1,381.00 | $1,381.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.00 / $222.00 / $222.00
| Facility | | $222.00 | $222.00 | $222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.55 / $239.67 / $327.00
| Professional | | $189.55 | $239.67 | $327.00 |