- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $198.28 / $198.28 / $198.28
| Facility | | $198.28 | $198.28 | $198.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.28 / $219.64 / $219.64
| Professional | | $198.28 | $219.64 | $219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.80 / $301.27 / $308.76
| Professional | | $254.80 | $301.27 | $308.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.13 / $307.17 / $386.24
| Professional | | $304.13 | $307.17 | $386.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $80.87 / $198.28 / $1,295.00
| Facility | | $80.87 | $198.28 | $1,295.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.57 / $182.41 / $220.40
| Professional | | $108.57 | $182.41 | $220.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.06 / $182.41 / $217.14
| Professional | | $81.06 | $182.41 | $217.14 |