- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $123.03 / $269.15
| Professional | | $100.00 | $123.03 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $331.13 / $331.13
| Facility | | $263.03 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $165.96 / $213.80
| Professional | | $112.20 | $165.96 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $218.78 / $302.00
| Professional | | $147.91 | $218.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $147.91 / $177.83 / $331.13
| Professional | | $147.91 | $177.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.49 / $162.18 / $549.54
| Professional | | $117.49 | $162.18 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $208.93 / $309.03
| Professional | | $120.23 | $208.93 | $309.03 |