- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $144.54 / $218.78
| Professional | | $100.00 | $144.54 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $269.15
| Facility | | $223.87 | $223.87 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $239.88 / $245.47
| Facility | | $173.78 | $239.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $239.88 / $245.47
| Professional | | $173.78 | $239.88 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.90 / $223.87 / $269.15
| Facility | | $134.90 | $223.87 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $223.87
| Professional | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $158.49 / $263.03
| Professional | | $151.36 | $158.49 | $263.03 |