- 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
- $541.86 / $541.86 / $541.86
| Facility | | $541.86 | $541.86 | $541.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.00 / $950.92 / $950.92
| Professional | | $305.00 | $950.92 | $950.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.31 / $159.38 / $331.40
| Facility | | $142.31 | $159.38 | $331.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.31 / $253.43 / $396.42
| Professional | | $142.31 | $253.43 | $396.42 |