- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.64 / $167.64 / $190.26
| Professional | | $167.64 | $167.64 | $190.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.08 / $149.08 / $149.08
| Professional | | $149.08 | $149.08 | $149.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $255.35 / $482.97 / $599.87
| Facility | | $255.35 | $482.97 | $599.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.79 / $68.52 / $164.89
| Professional | | $38.79 | $68.52 | $164.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.28 / $208.91 / $290.13
| Professional | | $167.28 | $208.91 | $290.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,500.00 / $2,750.00 / $3,500.00
| Professional | | $2,500.00 | $2,750.00 | $3,500.00 |