- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.85 / $1,071.22 / $1,071.22
| Professional | | $308.85 | $1,071.22 | $1,071.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.00 / $288.00 / $288.00
| Professional | | $288.00 | $288.00 | $288.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $177.64 / $309.66 / $309.66
| Facility | | $177.64 | $309.66 | $309.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.64 / $251.81 / $309.66
| Professional | | $177.64 | $251.81 | $309.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.26 / $294.91 / $309.66
| Facility | | $155.26 | $294.91 | $309.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.64 / $232.41 / $309.88
| Professional | | $177.64 | $232.41 | $309.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.56 / $138.91 / $231.54
| Professional | | $125.56 | $138.91 | $231.54 |