- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.60 / $403.06 / $403.06
| Professional | | $241.60 | $403.06 | $403.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.55 / $354.55 / $403.00
| Facility | | $354.55 | $354.55 | $403.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $301.37 / $354.55 / $617.63
| Professional | | $301.37 | $354.55 | $617.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.84 / $403.06 / $575.09
| Facility | | $230.84 | $403.06 | $575.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $575.09 / $575.09 / $575.09
| Professional | | $575.09 | $575.09 | $575.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.61 / $325.52 / $549.05
| Professional | | $230.61 | $325.52 | $549.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $633.83 / $2,544.80 / $2,544.80
| Facility | | $633.83 | $2,544.80 | $2,544.80 |