- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.27 / $315.27 / $401.15
| Professional | | $315.27 | $315.27 | $401.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.64 / $218.87 / $273.25
| Professional | | $204.64 | $218.87 | $273.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.05 / $712.05 / $712.05
| Facility | | $712.05 | $712.05 | $712.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $414.67 / $479.77 / $736.00
| Professional | | $414.67 | $479.77 | $736.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.27 / $315.27 / $315.27
| Professional | | $315.27 | $315.27 | $315.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.58 / $446.85 / $558.55
| Professional | | $302.58 | $446.85 | $558.55 |