- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.72 / $225.72 / $282.14
| Professional | | $225.72 | $225.72 | $282.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $472.22 / $472.22 / $472.22
| Facility | | $472.22 | $472.22 | $472.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.00 / $626.71 / $626.71
| Professional | | $143.00 | $626.71 | $626.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.61 / $193.70 / $259.95
| Facility | | $162.61 | $193.70 | $259.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $203.74 / $277.02
| Professional | | $150.00 | $203.74 | $277.02 |