- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.14 / $144.62 / $150.58
| Professional | | $104.14 | $144.62 | $150.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.37 / $171.61 / $316.64
| Professional | | $85.37 | $171.61 | $316.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $31.00 / $173.35 / $256.85
| Facility | | $31.00 | $173.35 | $256.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.44 / $201.57 / $1,157.24
| Professional | | $84.44 | $201.57 | $1,157.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.28 / $117.40 / $250.18
| Professional | | $16.28 | $117.40 | $250.18 |