- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.48 / $342.67 / $428.34
| Professional | | $249.48 | $342.67 | $428.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.67 / $200.00 / $200.00
| Facility | | $116.67 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.13 / $228.13 / $228.13
| Professional | | $228.13 | $228.13 | $228.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.85 / $198.26 / $315.35
| Facility | | $157.85 | $198.26 | $315.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.85 / $209.93 / $315.35
| Professional | | $157.85 | $209.93 | $315.35 |