- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.15 / $312.41 / $312.41
| Professional | | $232.15 | $312.41 | $312.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.30 / $239.76 / $258.39
| Professional | | $221.30 | $239.76 | $258.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $193.40 / $193.40 / $247.81
| Facility | | $193.40 | $193.40 | $247.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.77 / $193.40 / $254.01
| Professional | | $23.77 | $193.40 | $254.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $232.15 / $241.53 / $312.41
| Professional | | $232.15 | $241.53 | $312.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.29 / $98.10 / $324.16
| Professional | | $18.29 | $98.10 | $324.16 |