- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.11 / $120.73 / $740.36
| Professional | | $101.11 | $120.73 | $740.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.90 / $207.90 / $207.90
| Professional | | $207.90 | $207.90 | $207.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $125.61 / $223.53 / $223.53
| Facility | | $125.61 | $223.53 | $223.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.61 / $223.53 / $223.53
| Professional | | $125.61 | $223.53 | $223.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $115.10 / $212.89 / $223.53
| Facility | | $115.10 | $212.89 | $223.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.77 / $171.49 / $225.69
| Professional | | $167.77 | $171.49 | $225.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.64 / $100.29 / $153.46
| Professional | | $90.64 | $100.29 | $153.46 |