- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.68 / $342.68 / $342.68
| Professional | | $342.68 | $342.68 | $342.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.77 / $330.77 / $396.27
| Facility | | $330.77 | $330.77 | $396.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.97 / $330.77 / $506.25
| Professional | | $35.97 | $330.77 | $506.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.80 / $241.24 / $382.46
| Professional | | $136.80 | $241.24 | $382.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.88 / $249.88 / $395.10
| Professional | | $249.88 | $249.88 | $395.10 |