- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.51 / $46.71 / $261.70
| Professional | | $25.51 | $46.71 | $261.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.57 / $455.80 / $476.40
| Facility | | $207.57 | $455.80 | $476.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.13 / $68.13 / $219.10
| Facility | | $68.13 | $68.13 | $219.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $18.52 / $50.23 / $172.18
| Professional | | $18.52 | $50.23 | $172.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $68.13 / $68.13 / $219.10
| Facility | | $68.13 | $68.13 | $219.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.66 / $50.23 / $172.18
| Professional | | $21.66 | $50.23 | $172.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $25.40 / $52.37 / $140.00
| Professional | | $25.40 | $52.37 | $140.00 |