- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.33 / $350.74 / $350.74
| Professional | | $257.33 | $350.74 | $350.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.55 / $307.55 / $312.00
| Facility | | $307.55 | $307.55 | $312.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.42 / $353.87 / $725.63
| Professional | | $261.42 | $353.87 | $725.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.91 / $350.74 / $420.89
| Facility | | $143.91 | $350.74 | $420.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.00 / $283.00 / $333.59
| Professional | | $283.00 | $283.00 | $333.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.93 / $237.70 / $391.88
| Professional | | $143.93 | $237.70 | $391.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.50 / $2,378.23 / $2,378.23
| Facility | | $458.50 | $2,378.23 | $2,378.23 |