- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $241.52 / $249.31 / $311.64
| Professional | | $241.52 | $249.31 | $311.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.65 / $186.21 / $306.11
| Facility | | $128.65 | $186.21 | $306.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.00 / $478.52 / $492.17
| Professional | | $218.00 | $478.52 | $492.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $172.00 / $172.00 / $172.00
| Facility | | $172.00 | $172.00 | $172.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.00 / $209.44 / $222.53
| Professional | | $158.00 | $209.44 | $222.53 |