- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.30 / $267.30 / $334.12
| Professional | | $267.30 | $267.30 | $334.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $378.06 / $378.06 / $378.06
| Facility | | $378.06 | $378.06 | $378.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.00 / $602.61 / $602.61
| Professional | | $198.00 | $602.61 | $602.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.19 / $197.44 / $219.46
| Facility | | $157.19 | $197.44 | $219.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.00 / $214.57 / $262.70
| Professional | | $145.00 | $214.57 | $262.70 |