- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.06 / $117.46 / $135.97
| Professional | | $106.06 | $117.46 | $135.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.38 / $156.38 / $156.38
| Professional | | $156.38 | $156.38 | $156.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.06 / $119.66 / $142.87
| Facility | | $106.06 | $119.66 | $142.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $47.44 / $71.27 / $190.08
| Professional | | $47.44 | $71.27 | $190.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.39 / $68.09 / $111.81
| Professional | | $40.39 | $68.09 | $111.81 |