- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.55 / $269.87 / $286.74
| Professional | | $198.55 | $269.87 | $286.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.62 / $267.62 / $292.50
| Facility | | $267.62 | $267.62 | $292.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.48 / $267.62 / $445.88
| Professional | | $227.48 | $267.62 | $445.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.09 / $280.08 / $332.35
| Facility | | $234.09 | $280.08 | $332.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.14 / $302.14 / $302.14
| Professional | | $302.14 | $302.14 | $302.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.09 / $198.48 / $350.55
| Professional | | $134.09 | $198.48 | $350.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $1,827.09 / $1,827.09
| Facility | | $100.00 | $1,827.09 | $1,827.09 |