- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $173.78 / $234.42
| Professional | | $141.25 | $173.78 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.33 / $102.33 / $102.33
| Professional | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.18 / $208.93 / $257.04
| Facility | | $162.18 | $208.93 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.18 / $208.93 / $257.04
| Professional | | $162.18 | $208.93 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $218.78 / $218.78
| Facility | | $151.36 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $104.71
| Professional | | $100.00 | $100.00 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.50 / $104.71 / $151.36
| Professional | | $95.50 | $104.71 | $151.36 |