- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.11 / $200.57 / $200.57
| Professional | | $199.11 | $200.57 | $200.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.90 / $264.73 / $268.13
| Professional | | $223.90 | $264.73 | $268.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.50 / $280.27 / $352.43
| Professional | | $277.50 | $280.27 | $352.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $199.11 / $200.57 / $239.94
| Facility | | $199.11 | $200.57 | $239.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.40 / $99.56 / $1,580.44
| Professional | | $95.40 | $99.56 | $1,580.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.54 / $99.56 / $316.08
| Professional | | $93.54 | $99.56 | $316.08 |