- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $22.91 / $33.11 / $45.71
| Professional | | $22.91 | $33.11 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.15 / $44.67 / $100.00
| Professional | | $37.15 | $44.67 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.62 / $31.62 / $141.25
| Professional | | $31.62 | $31.62 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.88 / $40.74 / $114.82
| Professional | | $33.88 | $40.74 | $114.82 |