- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.47 / $375.00 / $1,323.81
| Professional | | $207.47 | $375.00 | $1,323.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $235.16 / $321.79 / $408.77
| Facility | | $235.16 | $321.79 | $408.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.06 / $304.18 / $547.89
| Professional | | $226.06 | $304.18 | $547.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $209.17 / $321.79 / $408.77
| Facility | | $209.17 | $321.79 | $408.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.83 / $338.08 / $521.24
| Professional | | $202.83 | $338.08 | $521.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.17 / $204.35 / $409.44
| Professional | | $198.17 | $204.35 | $409.44 |