- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.34 / $115.80 / $115.80
| Professional | | $98.34 | $115.80 | $115.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $249.57 / $297.18 / $342.28
| Facility | | $249.57 | $297.18 | $342.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $83.02 / $257.89 / $257.89
| Professional | | $83.02 | $257.89 | $257.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.00 / $119.00 / $119.00
| Professional | | $119.00 | $119.00 | $119.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.11 / $232.11 / $278.08
| Professional | | $232.11 | $232.11 | $278.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.34 / $115.80 / $115.80
| Professional | | $98.34 | $115.80 | $115.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.36 / $275.48 / $326.50
| Professional | | $109.36 | $275.48 | $326.50 |