- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $100.00 / $141.25
| Professional | | $77.62 | $100.00 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $141.25 / $141.25
| Professional | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.72 / $109.65 / $141.25
| Professional | | $97.72 | $109.65 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $151.36 / $151.36 / $151.36
| Facility | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $102.33 / $165.96
| Professional | | $75.86 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $100.00 / $134.90
| Professional | | $75.86 | $100.00 | $134.90 |