- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.81 / $241.24 / $301.55
| Professional | | $213.81 | $241.24 | $301.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.81 / $266.14 / $625.83
| Facility | | $138.81 | $266.14 | $625.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.00 / $921.00 / $921.00
| Professional | | $163.00 | $921.00 | $921.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $375.00 / $375.00
| Facility | | $375.00 | $375.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.85 / $343.14 / $405.79
| Professional | | $190.85 | $343.14 | $405.79 |