- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.73 / $151.33 / $310.44
| Professional | | $112.73 | $151.33 | $310.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.30 / $183.43 / $381.76
| Professional | | $89.30 | $183.43 | $381.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.78 / $210.42 / $256.00
| Facility | | $116.78 | $210.42 | $256.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.18 / $210.91 / $1,210.74
| Professional | | $90.18 | $210.91 | $1,210.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.18 / $122.84 / $261.81
| Professional | | $90.18 | $122.84 | $261.81 |