- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.75 / $170.47 / $194.69
| Professional | | $155.75 | $170.47 | $194.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $134.00 / $134.00 / $134.00
| Facility | | $134.00 | $134.00 | $134.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $115.00 / $185.70 / $459.01
| Professional | | $115.00 | $185.70 | $459.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $110.20 / $138.41 / $177.60
| Facility | | $110.20 | $138.41 | $177.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.20 / $138.41 / $185.70
| Professional | | $110.20 | $138.41 | $185.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $156.10 / $222.60
| Professional | | $103.00 | $156.10 | $222.60 |