- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.25 / $143.82 / $143.82
| Professional | | $108.25 | $143.82 | $143.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $83.15 / $83.15 / $83.15
| Facility | | $83.15 | $83.15 | $83.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.70 / $83.15 / $228.75
| Professional | | $60.70 | $83.15 | $228.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.28 / $143.82 / $172.58
| Facility | | $137.28 | $143.82 | $172.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.07 / $173.07 / $173.07
| Professional | | $173.07 | $173.07 | $173.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.05 / $104.88 / $174.80
| Professional | | $69.05 | $104.88 | $174.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $970.44 / $970.44
| Facility | | $100.00 | $970.44 | $970.44 |