- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.06 / $565.07 / $565.07
| Professional | | $101.06 | $565.07 | $565.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $127.43 / $171.37 / $259.69
| Facility | | $127.43 | $171.37 | $259.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.23 / $126.48 / $127.43
| Professional | | $44.23 | $126.48 | $127.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.59 / $149.40 / $259.69
| Facility | | $93.59 | $149.40 | $259.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.09 / $79.09 / $127.43
| Professional | | $79.09 | $79.09 | $127.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.85 / $36.90 / $88.54
| Professional | | $36.85 | $36.90 | $88.54 |