- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.32 / $109.36 / $157.37
| Professional | | $100.32 | $109.36 | $157.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.96 / $130.54 / $199.92
| Professional | | $110.96 | $130.54 | $199.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.35 / $116.35 / $1,863.00
| Facility | | $116.35 | $116.35 | $1,863.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.23 / $131.43 / $227.49
| Professional | | $104.23 | $131.43 | $227.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.57 / $165.74 / $289.02
| Professional | | $112.57 | $165.74 | $289.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $99.89 / $109.36 / $132.38
| Professional | | $99.89 | $109.36 | $132.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.63 / $142.30 / $202.67
| Professional | | $100.63 | $142.30 | $202.67 |