- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.53 / $199.53 / $251.19
| Professional | | $199.53 | $199.53 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.33 / $173.78 / $302.00
| Facility | | $93.33 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $398.11 / $398.11
| Professional | | $144.54 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |