- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $103.00 / $103.00 / $103.00
| Professional | | $103.00 | $103.00 | $103.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21.98 / $31.79 / $63.08
| Facility | | $21.98 | $31.79 | $63.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4.63 / $5.47 / $29.84
| Professional | | $4.63 | $5.47 | $29.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $75.38 / $90.00 / $109.64
| Facility | | $75.38 | $90.00 | $109.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $24.37 / $25.34 / $30.46
| Professional | | $24.37 | $25.34 | $30.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.09 / $30.09 / $32.02
| Professional | | $30.09 | $30.09 | $32.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11.88 / $11.88 / $19.30
| Facility | | $11.88 | $11.88 | $19.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11.87 / $17.23 / $48.84
| Professional | | $11.87 | $17.23 | $48.84 |