- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.10 / $238.46 / $298.07
| Professional | | $210.10 | $238.46 | $298.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $178.57 / $178.57 / $5,832.26
| Facility | | $178.57 | $178.57 | $5,832.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.57 / $238.46 / $337.44
| Professional | | $178.57 | $238.46 | $337.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $176.11 / $238.46 / $3,355.28
| Facility | | $176.11 | $238.46 | $3,355.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $337.44 / $512.13
| Professional | | $238.46 | $337.44 | $512.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.46 / $238.46 / $238.46
| Professional | | $238.46 | $238.46 | $238.46 |