- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.76 / $138.85 / $173.56
| Professional | | $119.76 | $138.85 | $173.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $88.76 / $131.79 / $442.12
| Facility | | $88.76 | $131.79 | $442.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $303.05 / $303.05
| Professional | | $75.00 | $303.05 | $303.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $73.78 / $103.00 / $121.58
| Facility | | $73.78 | $103.00 | $121.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.78 / $103.00 / $133.06
| Professional | | $73.78 | $103.00 | $133.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.00 / $192.00 / $192.00
| Professional | | $192.00 | $192.00 | $192.00 |