- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.66 / $129.66 / $137.77
| Professional | | $129.66 | $129.66 | $137.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $179.36 / $224.20
| Professional | | $105.39 | $179.36 | $224.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.97 / $220.47 / $275.00
| Professional | | $128.97 | $220.47 | $275.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $129.66 / $154.08 / $203.74
| Facility | | $129.66 | $154.08 | $203.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $210.87
| Professional | | $162.08 | $162.08 | $210.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.39 / $203.74 / $203.74
| Facility | | $105.39 | $203.74 | $203.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.39 / $105.39 / $203.74
| Professional | | $105.39 | $105.39 | $203.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.08 / $162.08 / $178.73
| Professional | | $162.08 | $162.08 | $178.73 |