- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $117.41 / $117.41
| Professional | | $103.00 | $117.41 | $117.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.97 / $306.23 / $414.42
| Professional | | $118.97 | $306.23 | $414.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.50 / $385.50 / $385.50
| Facility | | $385.50 | $385.50 | $385.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.94 / $801.06 / $801.06
| Professional | | $607.94 | $801.06 | $801.06 |
- Facility/Professional
- Professional
- Modifier
- 25
- Low / Median / High Price
- $284.07 / $284.07 / $284.07
| Professional | 25 | $284.07 | $284.07 | $284.07 |