- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $36.76 / $182.22 / $871.95
| Professional | | $36.76 | $182.22 | $871.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.53 / $51.53 / $51.53
| Facility | | $51.53 | $51.53 | $51.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.31 / $51.53 / $225.04
| Professional | | $45.31 | $51.53 | $225.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.53 / $273.00 / $303.60
| Facility | | $51.53 | $273.00 | $303.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $34.70 / $138.75 / $273.52
| Professional | | $34.70 | $138.75 | $273.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.79 / $269.63 / $402.38
| Professional | | $214.79 | $269.63 | $402.38 |