- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.02 / $306.02 / $382.53
| Professional | | $306.02 | $306.02 | $382.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $602.40 / $602.40 / $602.40
| Facility | | $602.40 | $602.40 | $602.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $849.56 / $849.56
| Professional | | $200.00 | $849.56 | $849.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $222.50 / $271.18 / $355.44
| Facility | | $222.50 | $271.18 | $355.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.00 / $278.89 / $378.64
| Professional | | $211.00 | $278.89 | $378.64 |