- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.58 / $364.58 / $455.72
| Professional | | $364.58 | $364.58 | $455.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.68 / $621.19 / $1,462.76
| Facility | | $346.68 | $621.19 | $1,462.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.00 / $2,521.23 / $2,521.23
| Professional | | $818.00 | $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 / $365.86 / $975.00
| Professional | | $202.43 | $365.86 | $975.00 |