- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.88 / $230.98 / $307.50
| Professional | | $181.88 | $230.98 | $307.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.14 / $360.14 / $973.66
| Professional | | $360.14 | $360.14 | $973.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $279.70 / $279.70 / $313.27
| Facility | | $279.70 | $279.70 | $313.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.70 / $313.27 / $313.27
| Professional | | $279.70 | $313.27 | $313.27 |