- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.46 / $209.51 / $244.22
| Professional | | $190.46 | $209.51 | $244.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $360.15 / $360.15 / $360.15
| Facility | | $360.15 | $360.15 | $360.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.32 / $243.00 / $262.97
| Professional | | $210.32 | $243.00 | $262.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.00 / $243.00 / $243.00
| Facility | | $243.00 | $243.00 | $243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $212.00 / $262.97 / $412.99
| Professional | | $212.00 | $262.97 | $412.99 |