- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.92 / $246.92 / $246.92
| Professional | | $246.92 | $246.92 | $246.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $308.64 / $383.00 / $790.00
| Professional | | $308.64 | $383.00 | $790.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $494.09 / $494.09 / $494.09
| Facility | | $494.09 | $494.09 | $494.09 |
- 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
- $103.71 / $103.71 / $246.92
| Professional | | $103.71 | $103.71 | $246.92 |