- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.19 / $146.72 / $151.11
| Professional | | $108.19 | $146.72 | $151.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $153.30 / $159.56 / $165.24
| Professional | | $153.30 | $159.56 | $165.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.77 / $153.77 / $153.77
| Facility | | $153.77 | $153.77 | $153.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.44 / $153.77 / $288.75
| Professional | | $18.44 | $153.77 | $288.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.02 / $25.02 / $25.02
| Professional | | $25.02 | $25.02 | $25.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.22 / $105.46 / $173.80
| Professional | | $63.22 | $105.46 | $173.80 |