- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.44 / $146.44 / $356.00
| Professional | | $146.44 | $146.44 | $356.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.00 / $410.80 / $680.42
| Facility | | $104.00 | $410.80 | $680.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.00 / $104.00 / $130.00
| Professional | | $78.00 | $104.00 | $130.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $643.95 / $643.95 / $643.95
| Facility | | $643.95 | $643.95 | $643.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.79 / $85.75 / $117.60
| Professional | | $22.79 | $85.75 | $117.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.25 / $289.25 / $289.25
| Professional | | $289.25 | $289.25 | $289.25 |