- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.45 / $364.58 / $455.72
| Professional | | $314.45 | $364.58 | $455.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $342.90 / $638.76 / $2,025.75
| Facility | | $342.90 | $638.76 | $2,025.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.23 / $2,521.23 / $2,521.23
| Professional | | $370.23 | $2,521.23 | $2,521.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.11 / $321.55 / $495.00
| Facility | | $195.11 | $321.55 | $495.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.43 / $370.23 / $911.47
| Professional | | $202.43 | $370.23 | $911.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.20 / $591.20 / $591.20
| Professional | | $591.20 | $591.20 | $591.20 |