- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.77 / $203.70 / $254.63
| Professional | | $118.77 | $203.70 | $254.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $238.16 / $238.16 / $378.27
| Facility | | $238.16 | $238.16 | $378.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $202.44 / $238.16 / $387.72
| Professional | | $202.44 | $238.16 | $387.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.15 / $240.37 / $1,682.37
| Facility | | $106.15 | $240.37 | $1,682.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.45 / $185.36 / $258.00
| Professional | | $111.45 | $185.36 | $258.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.02 / $185.36 / $235.88
| Professional | | $137.02 | $185.36 | $235.88 |