- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.23 / $173.78 / $218.78
| Professional | | $120.23 | $173.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $181.97 / $213.80
| Facility | | $181.97 | $181.97 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $131.83 / $190.55
| Professional | | $131.83 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $281.84 / $389.05
| Professional | | $223.87 | $281.84 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $144.54 / $181.97 / $281.84
| Facility | | $144.54 | $181.97 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $218.78 / $602.56
| Professional | | $100.00 | $218.78 | $602.56 |