- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.09 / $88.58 / $143.96
| Professional | | $61.09 | $88.58 | $143.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.56 / $101.78 / $182.60
| Professional | | $69.56 | $101.78 | $182.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.36 / $129.27 / $193.08
| Professional | | $90.36 | $129.27 | $193.08 |
- 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
- $78.81 / $133.85 / $207.14
| Professional | | $78.81 | $133.85 | $207.14 |