- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.07 / $275.00 / $275.00
| Professional | | $137.07 | $275.00 | $275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.62 / $222.84 / $371.05
| Professional | | $107.62 | $222.84 | $371.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.29 / $288.00 / $416.91
| Professional | | $207.29 | $288.00 | $416.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.00 / $342.88 / $480.73
| Facility | | $275.00 | $342.88 | $480.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.42 / $504.42 / $504.42
| Professional | | $504.42 | $504.42 | $504.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $310.94 / $392.88 / $716.21
| Professional | | $310.94 | $392.88 | $716.21 |