- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.83 / $148.31 / $195.50
| Professional | | $134.83 | $148.31 | $195.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $229.87 / $229.87 / $294.42
| Facility | | $229.87 | $229.87 | $294.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $148.32
| Professional | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.32 / $148.32 / $148.32
| Professional | | $148.32 | $148.32 | $148.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.81 / $158.62 / $244.01
| Professional | | $125.81 | $158.62 | $244.01 |