- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $239.88 / $239.88
| Professional | | $173.78 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $245.47 / $446.68
| Professional | | $177.83 | $245.47 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $239.88 / $302.00
| Facility | | $223.87 | $239.88 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $14.13 / $109.65 / $208.93
| Facility | | $14.13 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $173.78 / $281.84
| Professional | | $109.65 | $173.78 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $524.81 / $1,548.82 / $1,548.82
| Facility | | $524.81 | $1,548.82 | $1,548.82 |