- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $214.38 / $214.38
| Professional | | $150.00 | $214.38 | $214.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $301.97 / $340.71 / $356.94
| Facility | | $301.97 | $340.71 | $356.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.74 / $466.74 / $466.74
| Professional | | $466.74 | $466.74 | $466.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.00 / $193.00 / $255.00
| Facility | | $193.00 | $193.00 | $255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.70 / $246.70 / $272.20
| Professional | | $246.70 | $246.70 | $272.20 |