- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.06 / $211.80 / $398.25
| Professional | | $156.06 | $211.80 | $398.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.53 / $331.53 / $331.53
| Facility | | $331.53 | $331.53 | $331.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.80 / $331.53 / $552.00
| Professional | | $281.80 | $331.53 | $552.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.96 / $437.96 / $465.44
| Professional | | $437.96 | $437.96 | $465.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.45 / $317.45 / $317.45
| Professional | | $317.45 | $317.45 | $317.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.10 / $267.25 / $396.24
| Professional | | $197.10 | $267.25 | $396.24 |