- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.31 / $165.98 / $222.02
| Professional | | $124.31 | $165.98 | $222.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $201.00 / $201.00 / $201.00
| Facility | | $201.00 | $201.00 | $201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.00 / $201.00 / $201.00
| Professional | | $201.00 | $201.00 | $201.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.84 / $167.84 / $167.84
| Professional | | $167.84 | $167.84 | $167.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $32.34
| Professional | | $32.34 | $32.34 | $32.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.65 / $207.85 / $336.21
| Professional | | $164.65 | $207.85 | $336.21 |