- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $205.88 / $205.88 / $257.33
| Professional | | $205.88 | $205.88 | $257.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $305.00 / $305.00 / $541.86
| Facility | | $305.00 | $305.00 | $541.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.76 / $305.25 / $331.40
| Professional | | $237.76 | $305.25 | $331.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.31 / $159.38 / $305.00
| Facility | | $142.31 | $159.38 | $305.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.38 / $253.43 / $331.40
| Professional | | $159.38 | $253.43 | $331.40 |