- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.30 / $197.30 / $197.30
| Professional | | $197.30 | $197.30 | $197.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $320.27 / $379.76 / $703.96
| Facility | | $320.27 | $379.76 | $703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.49 / $242.48 / $242.48
| Professional | | $210.49 | $242.48 | $242.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.53 / $238.16 / $378.27
| Facility | | $180.53 | $238.16 | $378.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $171.56 / $238.16 / $274.02
| Professional | | $171.56 | $238.16 | $274.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.56 / $138.56 / $197.30
| Professional | | $138.56 | $138.56 | $197.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.61 / $164.69 / $378.10
| Professional | | $109.61 | $164.69 | $378.10 |