- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $89.13 / $114.82 / $128.82
| Professional | | $89.13 | $114.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.86 / $100.00 / $151.36
| Professional | | $75.86 | $100.00 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $186.21 / $186.21 / $186.21
| Facility | | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $58.88 / $131.83
| Professional | | $50.12 | $58.88 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $40.74 / $67.61 / $97.72
| Professional | | $40.74 | $67.61 | $97.72 |