- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.40 / $163.61 / $204.51
| Professional | | $104.40 | $163.61 | $204.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $126.22 / $183.93 / $224.73
| Facility | | $126.22 | $183.93 | $224.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.00 / $322.00 / $491.77
| Professional | | $130.00 | $322.00 | $491.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $156.00 / $156.00 / $156.00
| Facility | | $156.00 | $156.00 | $156.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.20 / $143.00 / $156.00
| Professional | | $101.20 | $143.00 | $156.00 |