- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.31 / $114.25 / $276.48
| Professional | | $110.31 | $114.25 | $276.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.10 / $157.30 / $381.53
| Professional | | $149.10 | $157.30 | $381.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.23 / $161.54 / $397.17
| Professional | | $101.23 | $161.54 | $397.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.22 / $266.45 / $314.64
| Professional | | $126.22 | $266.45 | $314.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $95.15 / $95.15 / $95.15
| Facility | | $95.15 | $95.15 | $95.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $95.64 / $127.53 / $371.81
| Professional | | $95.64 | $127.53 | $371.81 |