- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.32 / $132.93 / $321.69
| Professional | | $122.32 | $132.93 | $321.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.58 / $243.44 / $431.26
| Professional | | $230.58 | $243.44 | $431.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.18 / $181.08 / $433.19
| Professional | | $119.18 | $181.08 | $433.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.60 / $312.47 / $312.47
| Professional | | $148.60 | $312.47 | $312.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.65 / $111.65 / $111.65
| Facility | | $111.65 | $111.65 | $111.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.72 / $151.47 / $436.03
| Professional | | $108.72 | $151.47 | $436.03 |