- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.12 / $162.12 / $202.65
| Professional | | $162.12 | $162.12 | $202.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $518.70 / $518.70 / $518.70
| Facility | | $518.70 | $518.70 | $518.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $215.00 / $510.52 / $510.52
| Professional | | $215.00 | $510.52 | $510.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.00 / $215.00 / $215.00
| Facility | | $215.00 | $215.00 | $215.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.99 / $146.38 / $231.00
| Professional | | $142.99 | $146.38 | $231.00 |