- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.39 / $112.39 / $112.39
| Professional | | $112.39 | $112.39 | $112.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,095.55 / $1,095.55 / $1,145.42
| Facility | | $1,095.55 | $1,095.55 | $1,145.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.21 / $164.21 / $164.21
| Facility | | $164.21 | $164.21 | $164.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.58 / $104.53 / $140.94
| Professional | | $44.58 | $104.53 | $140.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $164.21 / $164.21 / $164.21
| Facility | | $164.21 | $164.21 | $164.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.58 / $104.53 / $140.94
| Professional | | $44.58 | $104.53 | $140.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.38 / $58.87 / $350.00
| Professional | | $54.38 | $58.87 | $350.00 |