- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.06 / $130.22 / $130.22
| Professional | | $78.06 | $130.22 | $130.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.47 / $114.47 / $140.40
| Facility | | $114.47 | $114.47 | $140.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.12 / $114.47 / $202.50
| Professional | | $100.12 | $114.47 | $202.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $74.70 / $130.22 / $195.30
| Facility | | $74.70 | $130.22 | $195.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.00 / $167.00 / $167.00
| Professional | | $167.00 | $167.00 | $167.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $72.56 / $102.30 / $203.39
| Professional | | $72.56 | $102.30 | $203.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $205.45 / $821.01 / $821.01
| Facility | | $205.45 | $821.01 | $821.01 |