- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $179.25 / $179.25 / $224.06
| Professional | | $179.25 | $179.25 | $224.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.20 / $532.20 / $532.20
| Facility | | $532.20 | $532.20 | $532.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $242.00 / $742.51 / $742.51
| Professional | | $242.00 | $742.51 | $742.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.81 / $220.43 / $242.00
| Facility | | $196.81 | $220.43 | $242.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.00 / $220.43 / $324.67
| Professional | | $153.00 | $220.43 | $324.67 |