- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $199.28 / $271.60 / $271.60
| Professional | | $199.28 | $271.60 | $271.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.50 / $238.16 / $238.16
| Facility | | $214.50 | $238.16 | $238.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $477.66
| Professional | | $202.44 | $238.16 | $477.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.15 / $271.60 / $325.92
| Facility | | $106.15 | $271.60 | $325.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $250.00 / $250.00
| Professional | | $250.00 | $250.00 | $250.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.45 / $191.71 / $322.39
| Professional | | $111.45 | $191.71 | $322.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $354.87 / $1,682.37 / $1,682.37
| Facility | | $354.87 | $1,682.37 | $1,682.37 |