- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $228.57 / $228.57 / $228.57
| Professional | | $228.57 | $228.57 | $228.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $367.50 / $448.69 / $862.62
| Professional | | $367.50 | $448.69 | $862.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $231.13 / $315.41 / $362.68
| Facility | | $231.13 | $315.41 | $362.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $256.69 / $1,469.65
| Professional | | $167.55 | $256.69 | $1,469.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $201.13 / $284.82
| Professional | | $167.55 | $201.13 | $284.82 |