- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $238.65 / $238.65 / $238.65
| Professional | | $238.65 | $238.65 | $238.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.25 / $644.25 / $644.25
| Professional | | $644.25 | $644.25 | $644.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $170.00
| Facility | | $170.00 | $170.00 | $170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.51 / $198.51 / $198.51
| Professional | | $198.51 | $198.51 | $198.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $170.00 / $170.00 / $170.00
| Facility | | $170.00 | $170.00 | $170.00 |