- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.10 / $252.10 / $315.13
| Professional | | $252.10 | $252.10 | $315.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $143.87 / $239.75 / $384.75
| Facility | | $143.87 | $239.75 | $384.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.57 / $511.57 / $511.57
| Professional | | $511.57 | $511.57 | $511.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.00 / $182.00 / $182.00
| Facility | | $182.00 | $182.00 | $182.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.00 / $170.00 / $229.77
| Professional | | $166.00 | $170.00 | $229.77 |