- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.32 / $101.90 / $185.88
| Professional | | $97.32 | $101.90 | $185.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.00 / $127.00 / $162.54
| Professional | | $127.00 | $127.00 | $162.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.51 / $135.51 / $135.51
| Facility | | $135.51 | $135.51 | $135.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $98.92 / $98.92 / $135.51
| Professional | | $98.92 | $98.92 | $135.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.44 / $237.77 / $342.39
| Professional | | $166.44 | $237.77 | $342.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.19 / $118.63 / $189.09
| Professional | | $94.19 | $118.63 | $189.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.99 / $129.99 / $166.44
| Professional | | $129.99 | $129.99 | $166.44 |