- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.27 / $66.30 / $131.01
| Professional | | $48.27 | $66.30 | $131.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $85.00 / $100.00 / $100.00
| Facility | | $85.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $37.00 / $152.16 / $152.16
| Professional | | $37.00 | $152.16 | $152.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.53 / $38.34 / $49.87
| Facility | | $30.53 | $38.34 | $49.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.53 / $45.92 / $52.51
| Professional | | $30.53 | $45.92 | $52.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $38.79 / $38.79 / $74.09
| Professional | | $38.79 | $38.79 | $74.09 |