- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.74 / $180.74 / $225.92
| Professional | | $180.74 | $180.74 | $225.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $170.00
| Facility | | $170.00 | $170.00 | $170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.96 / $190.30 / $518.29
| Professional | | $161.96 | $190.30 | $518.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.71 / $170.00 / $192.34
| Facility | | $116.71 | $170.00 | $192.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.44 / $183.00 / $207.25
| Professional | | $105.44 | $183.00 | $207.25 |