- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.72 / $115.58 / $125.10
| Professional | | $75.72 | $115.58 | $125.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.87 / $200.00 / $259.70
| Professional | | $142.87 | $200.00 | $259.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.29 / $58.29 / $58.29
| Professional | | $58.29 | $58.29 | $58.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.81 / $115.58 / $177.99
| Facility | | $111.81 | $115.58 | $177.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.49 / $67.09 / $83.86
| Professional | | $50.49 | $67.09 | $83.86 |