- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.50 / $309.50 / $386.88
| Professional | | $309.50 | $309.50 | $386.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $334.23 / $456.00 / $2,025.75
| Facility | | $334.23 | $456.00 | $2,025.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.54 / $935.00 / $5,432.00
| Professional | | $301.54 | $935.00 | $5,432.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $456.00 / $456.00 / $456.00
| Facility | | $456.00 | $456.00 | $456.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.56 / $313.26 / $1,115.00
| Professional | | $167.56 | $313.26 | $1,115.00 |