- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.70 / $349.62 / $536.61
| Professional | | $279.70 | $349.62 | $536.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $327.26 / $411.09 / $561.46
| Facility | | $327.26 | $411.09 | $561.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.00 / $1,286.00 / $1,306.17
| Professional | | $364.00 | $1,286.00 | $1,306.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.00 / $394.00 / $394.00
| Facility | | $394.00 | $394.00 | $394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.67 / $377.00 / $396.98
| Professional | | $252.67 | $377.00 | $396.98 |