- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.60 / $406.34 / $406.34
| Professional | | $35.60 | $406.34 | $406.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.25 / $102.26 / $128.59
| Professional | | $101.25 | $102.26 | $128.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $35.60 / $35.60 / $406.34
| Facility | | $35.60 | $35.60 | $406.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.95 / $88.38 / $3,919.21
| Professional | | $46.95 | $88.38 | $3,919.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $93.52 / $110.48
| Professional | | $46.77 | $93.52 | $110.48 |