- 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
- $1,035.15 / $1,035.15 / $1,035.15
| Facility | | $1,035.15 | $1,035.15 | $1,035.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $518.29 / $518.29
| Professional | | $170.00 | $518.29 | $518.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.71 / $116.71 / $192.34
| Facility | | $116.71 | $116.71 | $192.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.71 / $190.30 / $203.28
| Professional | | $116.71 | $190.30 | $203.28 |