- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $577.11 / $577.11 / $577.11
| Professional | | $577.11 | $577.11 | $577.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.00 / $251.00 / $251.00
| Facility | | $251.00 | $251.00 | $251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.23 / $251.00 / $258.52
| Professional | | $183.23 | $251.00 | $258.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.38 / $129.38 / $129.38
| Facility | | $129.38 | $129.38 | $129.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.61 / $640.01 / $1,010.54
| Professional | | $381.61 | $640.01 | $1,010.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.38 / $129.38 / $251.00
| Facility | | $129.38 | $129.38 | $251.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.23 / $251.00 / $470.74
| Professional | | $183.23 | $251.00 | $470.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $325.61 / $644.17 / $840.24
| Professional | | $325.61 | $644.17 | $840.24 |