- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.27 / $366.96 / $441.97
| Professional | | $306.27 | $366.96 | $441.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.70 / $103.00 / $178.70
| Professional | | $98.70 | $103.00 | $178.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $85.00 / $85.00
| Professional | | $85.00 | $85.00 | $85.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.26 / $206.26 / $348.00
| Facility | | $206.26 | $206.26 | $348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $458.53 / $458.53 / $459.01
| Professional | | $458.53 | $458.53 | $459.01 |