- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $91.54 / $105.94 / $122.60
| Professional | | $91.54 | $105.94 | $122.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.06 / $100.46 / $140.66
| Professional | | $69.06 | $100.46 | $140.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $141.06 / $172.14
| Professional | | $141.06 | $141.06 | $172.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.37 / $123.91 / $244.21
| Facility | | $93.37 | $123.91 | $244.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.48 / $141.30 / $882.23
| Professional | | $100.48 | $141.30 | $882.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.65 / $119.32 / $226.36
| Professional | | $97.65 | $119.32 | $226.36 |