- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.81 / $111.79 / $128.69
| Professional | | $101.81 | $111.79 | $128.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $50.91 / $90.36 / $158.41
| Facility | | $50.91 | $90.36 | $158.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $53.30 / $53.30 / $53.30
| Professional | | $53.30 | $53.30 | $53.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.45 / $208.45 / $208.45
| Facility | | $208.45 | $208.45 | $208.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.76 / $62.32 / $166.57
| Professional | | $39.76 | $62.32 | $166.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.09 / $73.16 / $164.50
| Professional | | $50.09 | $73.16 | $164.50 |