- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.31 / $109.25 / $196.47
| Professional | | $96.31 | $109.25 | $196.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.75 / $143.75 / $212.75
| Professional | | $143.75 | $143.75 | $212.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.19 / $109.97 / $280.00
| Professional | | $74.19 | $109.97 | $280.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.25 / $174.80 / $250.53
| Facility | | $109.25 | $174.80 | $250.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.75 / $201.25 / $530.44
| Professional | | $143.75 | $201.25 | $530.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.25 / $110.65 / $332.84
| Professional | | $86.25 | $110.65 | $332.84 |