- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $302.00 / $512.86
| Professional | | $204.17 | $302.00 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $354.81 / $354.81
| Professional | | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $933.25
| Facility | | $302.00 | $302.00 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $660.69
| Professional | | $218.78 | $218.78 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $363.08 / $645.65
| Facility | | $316.23 | $363.08 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $239.88 / $363.08
| Professional | | $158.49 | $239.88 | $363.08 |