- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $194.98 / $346.74
| Professional | | $154.88 | $194.98 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Facility | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $363.08
| Facility | | $275.42 | $275.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.42 / $234.42 / $309.03
| Professional | | $234.42 | $234.42 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $117.49 / $204.17 / $234.42
| Facility | | $117.49 | $204.17 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $154.88 / $239.88
| Professional | | $138.04 | $154.88 | $239.88 |