- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.08 / $173.80 / $645.30
| Professional | | $98.08 | $173.80 | $645.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $148.28 / $148.28 / $148.28
| Facility | | $148.28 | $148.28 | $148.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.53 / $140.61 / $208.36
| Professional | | $78.53 | $140.61 | $208.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.11 / $104.48 / $152.77
| Facility | | $74.11 | $104.48 | $152.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.04 / $165.45 / $245.00
| Professional | | $96.04 | $165.45 | $245.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $196.55 / $224.63
| Professional | | $154.44 | $196.55 | $224.63 |