- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.13 / $155.13 / $193.93
| Professional | | $155.13 | $155.13 | $193.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $346.11 / $346.11 / $346.11
| Facility | | $346.11 | $346.11 | $346.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $114.00 / $683.00 / $683.00
| Professional | | $114.00 | $683.00 | $683.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.20 / $138.41 / $176.94
| Facility | | $110.20 | $138.41 | $176.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $138.41 / $187.63
| Professional | | $110.20 | $138.41 | $187.63 |