- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $62.06 / $93.22 / $149.78
| Professional | | $62.06 | $93.22 | $149.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $69.06 / $103.00 / $188.04
| Professional | | $69.06 | $103.00 | $188.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.31 / $136.60 / $202.52
| Professional | | $93.31 | $136.60 | $202.52 |
- 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
- $80.52 / $140.38 / $213.30
| Professional | | $80.52 | $140.38 | $213.30 |