- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.06 / $44.09 / $61.69
| Professional | | $35.06 | $44.09 | $61.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.63 / $139.63 / $139.63
| Facility | | $139.63 | $139.63 | $139.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.19 / $2,959.51 / $2,959.51
| Professional | | $106.19 | $2,959.51 | $2,959.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $25.51 / $32.04 / $38.00
| Facility | | $25.51 | $32.04 | $38.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.33 / $36.15 / $43.52
| Professional | | $29.33 | $36.15 | $43.52 |