- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.44 / $245.44 / $245.44
| Professional | | $245.44 | $245.44 | $245.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $564.62 / $637.44
| Facility | | $0.02 | $564.62 | $637.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.84 / $364.84 / $364.84
| Professional | | $364.84 | $364.84 | $364.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $814.00 / $814.00 / $814.00
| Facility | | $814.00 | $814.00 | $814.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.65 / $165.21 / $397.14
| Professional | | $115.65 | $165.21 | $397.14 |