- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.41 / $160.41 / $160.41
| Facility | | $160.41 | $160.41 | $160.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15.84 / $53.94 / $408.00
| Professional | | $15.84 | $53.94 | $408.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $93.76 / $108.55 / $150.30
| Facility | | $93.76 | $108.55 | $150.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.38 / $35.38 / $124.73
| Professional | | $32.38 | $35.38 | $124.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.76 / $81.30 / $117.60
| Professional | | $32.76 | $81.30 | $117.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.76 / $81.30 / $117.60
| Professional | | $32.76 | $81.30 | $117.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $32.34 / $40.07 / $74.52
| Professional | | $32.34 | $40.07 | $74.52 |