- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.70 / $275.70 / $275.70
| Professional | | $275.70 | $275.70 | $275.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $216.00 / $270.00 / $340.40
| Professional | | $216.00 | $270.00 | $340.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $226.63 / $226.63 / $342.14
| Facility | | $226.63 | $226.63 | $342.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.64 / $192.64 / $192.64
| Professional | | $192.64 | $192.64 | $192.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.70 / $275.70 / $330.84
| Facility | | $275.70 | $275.70 | $330.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.31 / $260.31 / $260.31
| Professional | | $260.31 | $260.31 | $260.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $70.00
| Professional | | $30.00 | $30.00 | $70.00 |