- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.33 / $114.41 / $196.72
| Professional | | $32.33 | $114.41 | $196.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $37.82 / $99.05 / $182.32
| Facility | | $37.82 | $99.05 | $182.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.94 / $150.94 / $322.23
| Professional | | $150.94 | $150.94 | $322.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.21 / $107.21 / $107.21
| Facility | | $107.21 | $107.21 | $107.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.21 / $107.21 / $140.27
| Professional | | $29.21 | $107.21 | $140.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.14 / $116.62 / $118.57
| Professional | | $86.14 | $116.62 | $118.57 |