- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.04 / $78.48 / $100.83
| Professional | | $65.04 | $78.48 | $100.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.68 / $104.33 / $153.01
| Professional | | $88.68 | $104.33 | $153.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.20 / $126.10 / $184.58
| Professional | | $58.20 | $126.10 | $184.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $540.00 / $1,183.00 / $4,915.00
| Facility | | $540.00 | $1,183.00 | $4,915.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.65 / $113.39 / $162.62
| Professional | | $82.65 | $113.39 | $162.62 |