- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $144.54 / $218.78
| Professional | | $123.03 | $144.54 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $104.71 / $123.03
| Professional | | $104.71 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.48 / $97.72 / $162.18
| Facility | | $11.48 | $97.72 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $154.88 / $223.87
| Professional | | $100.00 | $154.88 | $223.87 |