- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $257.04 / $354.81
| Professional | | $173.78 | $257.04 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $676.08
| Facility | | $251.19 | $251.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $194.98 / $549.54
| Professional | | $194.98 | $194.98 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $302.00 / $309.03
| Facility | | $269.15 | $302.00 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $199.53 / $302.00
| Professional | | $134.90 | $199.53 | $302.00 |