- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.02 / $209.33 / $231.96
| Professional | | $198.02 | $209.33 | $231.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $299.86 / $333.18 / $347.94
| Facility | | $299.86 | $333.18 | $347.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $374.82 / $374.82 / $374.82
| Professional | | $374.82 | $374.82 | $374.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.69 / $836.69 / $836.69
| Facility | | $836.69 | $836.69 | $836.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.81 / $169.73 / $408.00
| Professional | | $118.81 | $169.73 | $408.00 |