- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $173.78 / $302.00
| Professional | | $151.36 | $173.78 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Facility | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $380.19
| Facility | | $218.78 | $218.78 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $162.18 / $302.00
| Professional | | $162.18 | $162.18 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.82 / $204.17 / $275.42
| Facility | | $114.82 | $204.17 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $151.36 / $234.42
| Professional | | $138.04 | $151.36 | $234.42 |