- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.16 / $151.60 / $157.85
| Professional | | $109.16 | $151.60 | $157.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.45 / $179.49 / $382.44
| Professional | | $89.45 | $179.49 | $382.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.00 / $181.72 / $269.24
| Facility | | $78.00 | $181.72 | $269.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $211.30 / $1,213.06
| Professional | | $88.51 | $211.30 | $1,213.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $88.51 / $136.05 / $262.26
| Professional | | $88.51 | $136.05 | $262.26 |