- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.58 / $346.43 / $346.43
| Professional | | $298.58 | $346.43 | $346.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.62 / $298.58 / $343.38
| Facility | | $138.62 | $298.58 | $343.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.56 / $501.80 / $501.80
| Professional | | $155.56 | $501.80 | $501.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $92.74 / $116.67 / $3,500.00
| Professional | | $92.74 | $116.67 | $3,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.15 / $211.94 / $242.82
| Professional | | $180.15 | $211.94 | $242.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.42 / $394.44 / $727.18
| Professional | | $318.42 | $394.44 | $727.18 |