- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.38 / $141.38 / $176.72
| Professional | | $141.38 | $141.38 | $176.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $65.00 / $423.00 / $423.00
| Facility | | $65.00 | $423.00 | $423.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.00 / $583.46 / $583.46
| Professional | | $195.00 | $583.46 | $583.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $155.10 / $173.71 / $195.00
| Facility | | $155.10 | $173.71 | $195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.00 / $173.71 / $255.51
| Professional | | $123.00 | $173.71 | $255.51 |