- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.78 / $120.00 / $134.78
| Professional | | $32.78 | $120.00 | $134.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.18 / $291.32 / $339.44
| Facility | | $150.18 | $291.32 | $339.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $230.76 / $230.76 / $230.76
| Facility | | $230.76 | $230.76 | $230.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.43 / $89.60 / $115.01
| Professional | | $52.43 | $89.60 | $115.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $41.75 / $56.48 / $79.90
| Professional | | $41.75 | $56.48 | $79.90 |