- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.02 / $103.36 / $537.19
| Professional | | $91.02 | $103.36 | $537.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $157.21 / $157.21 / $157.21
| Facility | | $157.21 | $157.21 | $157.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.81 / $157.21 / $169.36
| Professional | | $126.81 | $157.21 | $169.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.51 / $182.00 / $187.85
| Facility | | $77.51 | $182.00 | $187.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.43 / $143.16 / $206.50
| Professional | | $95.43 | $143.16 | $206.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.79 / $175.80 / $274.70
| Professional | | $142.79 | $175.80 | $274.70 |