- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.43 / $234.43 / $234.43
| Professional | | $234.43 | $234.43 | $234.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.80 / $244.80 / $288.20
| Professional | | $244.80 | $244.80 | $288.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $240.50 / $240.50 / $324.72
| Facility | | $240.50 | $240.50 | $324.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.88 / $240.50 / $240.50
| Professional | | $26.88 | $240.50 | $240.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.58 / $164.58 / $234.43
| Professional | | $164.58 | $164.58 | $234.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.77 / $164.66 / $422.77
| Professional | | $109.77 | $164.66 | $422.77 |