- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.25 / $218.25 / $218.25
| Professional | | $218.25 | $218.25 | $218.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $523.00 / $523.00 / $523.00
| Facility | | $523.00 | $523.00 | $523.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $523.00 / $523.00 / $523.00
| Professional | | $523.00 | $523.00 | $523.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.00 / $363.00 / $525.00
| Professional | | $363.00 | $363.00 | $525.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.55 / $340.43 / $405.09
| Professional | | $272.55 | $340.43 | $405.09 |