- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.04 / $171.84 / $342.00
| Professional | | $111.04 | $171.84 | $342.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.78 / $186.86 / $251.25
| Professional | | $120.78 | $186.86 | $251.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.80 / $165.41 / $211.82
| Facility | | $113.80 | $165.41 | $211.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.00 / $207.27 / $230.30
| Professional | | $190.00 | $207.27 | $230.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $32.34 / $213.90
| Professional | | $32.34 | $32.34 | $213.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.81 / $178.60 / $222.34
| Professional | | $151.81 | $178.60 | $222.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.38 / $168.97 / $222.05
| Professional | | $133.38 | $168.97 | $222.05 |