- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.60 / $227.92 / $252.56
| Professional | | $215.60 | $227.92 | $252.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.00 / $362.76 / $394.24
| Facility | | $308.00 | $362.76 | $394.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.00 / $231.00 / $376.35
| Professional | | $231.00 | $231.00 | $376.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $910.98 / $910.98 / $910.98
| Facility | | $910.98 | $910.98 | $910.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.02 / $422.87 / $860.49
| Professional | | $158.02 | $422.87 | $860.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.36 / $175.06 / $444.23
| Professional | | $129.36 | $175.06 | $444.23 |