- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.77 / $128.82 / $281.84
| Professional | | $46.77 | $128.82 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $87.10 / $134.90
| Facility | | $56.23 | $87.10 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $109.65 / $181.97
| Professional | | $61.66 | $109.65 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $131.83 / $141.25 / $173.78
| Professional | | $131.83 | $141.25 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $162.18 / $165.96
| Professional | | $138.04 | $162.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.66 / $104.71 / $162.18
| Professional | | $61.66 | $104.71 | $162.18 |