- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.21 / $98.21 / $127.71
| Professional | | $98.21 | $98.21 | $127.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $225.86 / $273.76 / $307.22
| Professional | | $225.86 | $273.76 | $307.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.11 / $157.68 / $198.26
| Professional | | $156.11 | $157.68 | $198.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.10 / $193.27 / $645.34
| Facility | | $95.10 | $193.27 | $645.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.06 / $97.30 / $232.96
| Professional | | $57.06 | $97.30 | $232.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $57.06 / $163.03 / $232.96
| Professional | | $57.06 | $163.03 | $232.96 |