- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.38 / $41.38 / $76.68
| Professional | | $41.38 | $41.38 | $76.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.00 / $102.00 / $187.00
| Professional | | $81.00 | $102.00 | $187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $56.03 / $93.21 / $162.63
| Professional | | $56.03 | $93.21 | $162.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $111.65 / $181.77 / $279.83
| Professional | | $111.65 | $181.77 | $279.83 |