- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.35 / $137.84 / $272.36
| Professional | | $100.35 | $137.84 | $272.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $123.81 / $185.61 / $185.61
| Facility | | $123.81 | $185.61 | $185.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $58.00 / $483.00 / $483.00
| Professional | | $58.00 | $483.00 | $483.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $66.53 / $83.00 / $89.78
| Facility | | $66.53 | $83.00 | $89.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.44 / $89.78 / $111.80
| Professional | | $65.44 | $89.78 | $111.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.09 / $79.09 / $156.90
| Professional | | $79.09 | $79.09 | $156.90 |