- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.31 / $243.70 / $243.70
| Professional | | $212.31 | $243.70 | $243.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.59 / $253.65 / $280.07
| Professional | | $185.59 | $253.65 | $280.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.56 / $205.56 / $205.56
| Professional | | $205.56 | $205.56 | $205.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Facility | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.33 / $183.95 / $488.25
| Professional | | $152.33 | $183.95 | $488.25 |