- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.78 / $166.78 / $208.47
| Professional | | $166.78 | $166.78 | $208.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.18 / $157.56 / $273.93
| Facility | | $127.18 | $157.56 | $273.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.00 / $426.00 / $426.00
| Professional | | $136.00 | $426.00 | $426.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.00 / $154.00 / $154.00
| Facility | | $154.00 | $154.00 | $154.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.00 / $160.82 / $174.67
| Professional | | $136.00 | $160.82 | $174.67 |