- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.71 / $193.71 / $193.71
| Professional | | $193.71 | $193.71 | $193.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.14 / $300.00 / $620.00
| Professional | | $242.14 | $300.00 | $620.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $387.31 / $387.31 / $387.31
| Facility | | $387.31 | $387.31 | $387.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $283.73 / $283.73 / $354.66
| Professional | | $283.73 | $283.73 | $354.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.36 / $86.36 / $205.63
| Professional | | $81.36 | $86.36 | $205.63 |