- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $113.94 / $834.26 / $834.26
| Professional | | $113.94 | $834.26 | $834.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.51 / $227.70 / $227.70
| Facility | | $135.51 | $227.70 | $227.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.51 / $185.17 / $227.70
| Professional | | $135.51 | $185.17 | $227.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.90 / $216.86 / $227.70
| Facility | | $120.90 | $216.86 | $227.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $135.51 / $170.90 / $227.87
| Professional | | $135.51 | $170.90 | $227.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.78 / $108.19 / $123.85
| Professional | | $97.78 | $108.19 | $123.85 |