- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.86 / $247.78 / $308.61
| Professional | | $160.86 | $247.78 | $308.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.80 / $264.80 / $264.80
| Professional | | $264.80 | $264.80 | $264.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $240.50
| Facility | | $240.50 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.88 / $240.50 / $386.25
| Professional | | $26.88 | $240.50 | $386.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.79 / $157.90 / $288.26
| Professional | | $98.79 | $157.90 | $288.26 |