- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.64 / $61.87 / $103.57
| Professional | | $51.64 | $61.87 | $103.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.83 / $61.34 / $141.00
| Facility | | $48.83 | $61.34 | $141.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $25.00 / $43.00
| Professional | | $17.00 | $25.00 | $43.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.79 / $52.90 / $81.30
| Professional | | $35.79 | $52.90 | $81.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $1,974.91 / $1,974.91
| Facility | | $85.00 | $1,974.91 | $1,974.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.00 / $236.59 / $236.59
| Professional | | $236.00 | $236.59 | $236.59 |