- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.15 / $110.15 / $137.69
| Professional | | $110.15 | $110.15 | $137.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.46 / $121.73 / $348.00
| Facility | | $118.46 | $121.73 | $348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $121.00 / $874.00 / $874.00
| Professional | | $121.00 | $874.00 | $874.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $136.00 / $136.00 / $136.00
| Facility | | $136.00 | $136.00 | $136.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.52 / $102.94 / $144.00
| Professional | | $100.52 | $102.94 | $144.00 |