- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.71 / $311.60 / $311.60
| Professional | | $225.71 | $311.60 | $311.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.78 / $219.78 / $219.78
| Facility | | $219.78 | $219.78 | $219.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.81 / $219.78 / $646.88
| Professional | | $186.81 | $219.78 | $646.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $141.35 / $311.60 / $373.92
| Facility | | $141.35 | $311.60 | $373.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $333.00 / $333.00 / $333.00
| Professional | | $333.00 | $333.00 | $333.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.66 / $204.60 / $329.49
| Professional | | $146.66 | $204.60 | $329.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $407.89 / $2,434.42 / $2,434.42
| Facility | | $407.89 | $2,434.42 | $2,434.42 |