- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $215.23 / $338.91
| Professional | | $172.18 | $215.23 | $338.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $215.00 / $282.10
| Facility | | $55.00 | $215.00 | $282.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.40 / $396.00 / $1,297.00
| Professional | | $154.40 | $396.00 | $1,297.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.22 / $215.00 / $215.00
| Facility | | $148.22 | $215.00 | $215.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.22 / $215.00 / $250.22
| Professional | | $148.22 | $215.00 | $250.22 |