- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $39.81 / $81.28 / $154.88
| Professional | | $39.81 | $81.28 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.90 / $75.86 / $144.54
| Professional | | $38.90 | $75.86 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.48 / $93.33 / $177.83
| Professional | | $52.48 | $93.33 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $338.84 / $1,412.54 / $6,456.54
| Facility | | $338.84 | $1,412.54 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $42.66 / $79.43 / $162.18
| Professional | | $42.66 | $79.43 | $162.18 |