- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $131.83 / $190.55
| Professional | | $100.00 | $131.83 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.87 / $223.87 / $251.19
| Facility | | $223.87 | $223.87 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $169.82 / $229.09
| Professional | | $128.82 | $169.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $194.98 / $275.42
| Professional | | $100.00 | $194.98 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $151.36 / $204.17
| Professional | | $107.15 | $151.36 | $204.17 |