- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.76 / $117.44 / $184.70
| Professional | | $87.76 | $117.44 | $184.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.08 / $130.02 / $235.55
| Professional | | $96.08 | $130.02 | $235.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.49 / $170.78 / $252.28
| Professional | | $120.49 | $170.78 | $252.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,401.00 / $4,915.00
| Facility | | $540.00 | $1,401.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.22 / $174.87 / $270.08
| Professional | | $102.22 | $174.87 | $270.08 |