- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $28.18 / $85.11
| Professional | | $15.85 | $28.18 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.85 / $26.30 / $66.07
| Professional | | $15.85 | $26.30 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.38 / $39.81 / $91.20
| Professional | | $21.38 | $39.81 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $316.23 / $1,412.54 / $6,456.54
| Facility | | $316.23 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $19.50 / $39.81 / $77.62
| Professional | | $19.50 | $39.81 | $77.62 |